Provider Demographics
NPI:1184795684
Name:BERGSTROM FAMILY EYECARE P S
Entity type:Organization
Organization Name:BERGSTROM FAMILY EYECARE P S
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:BALDWIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:509-493-2020
Mailing Address - Street 1:PO BOX 1789
Mailing Address - Street 2:
Mailing Address - City:WHITE SALMON
Mailing Address - State:WA
Mailing Address - Zip Code:98672-1789
Mailing Address - Country:US
Mailing Address - Phone:509-493-2020
Mailing Address - Fax:509-493-2023
Practice Address - Street 1:950 E JEWETT BLVD.
Practice Address - Street 2:
Practice Address - City:WHITE SALMON
Practice Address - State:WA
Practice Address - Zip Code:98672
Practice Address - Country:US
Practice Address - Phone:509-493-2020
Practice Address - Fax:509-493-2023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA600024606332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2215309Medicaid
WA2215309Medicaid