Provider Demographics
NPI:1205121159
Name:VISION PLUS IN LYNDEN
Entity type:Organization
Organization Name:VISION PLUS IN LYNDEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:AGINSKY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-393-4000
Mailing Address - Street 1:1824 FRONT ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:LYNDEN
Mailing Address - State:WA
Mailing Address - Zip Code:98264-1729
Mailing Address - Country:US
Mailing Address - Phone:360-933-1815
Mailing Address - Fax:360-933-4617
Practice Address - Street 1:1824 FRONT ST
Practice Address - Street 2:SUITE B
Practice Address - City:LYNDEN
Practice Address - State:WA
Practice Address - Zip Code:98264-1729
Practice Address - Country:US
Practice Address - Phone:360-933-1815
Practice Address - Fax:360-933-4617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-17
Last Update Date:2012-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA603116349152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2014245Medicaid
WA2014245Medicaid