Provider Demographics
NPI:1205961836
Name:KORNMESSER OPTOMETRY CLINIC INC PS
Entity type:Organization
Organization Name:KORNMESSER OPTOMETRY CLINIC INC PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:SLADEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-357-5548
Mailing Address - Street 1:1405 HARRISON AVE NW STE 101
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-5327
Mailing Address - Country:US
Mailing Address - Phone:360-357-5549
Mailing Address - Fax:360-786-9797
Practice Address - Street 1:1405 HARRISON AVE NW STE 101
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-5327
Practice Address - Country:US
Practice Address - Phone:360-357-5549
Practice Address - Fax:360-786-9797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2495208Medicaid
WA2495208Medicaid