Provider Demographics
NPI:1255406351
Name:HIGHLAND VISION CLINIC, P.S.
Entity type:Organization
Organization Name:HIGHLAND VISION CLINIC, P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:OTTO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:206-542-7406
Mailing Address - Street 1:701 N 182ND ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-4430
Mailing Address - Country:US
Mailing Address - Phone:206-542-7406
Mailing Address - Fax:206-546-2266
Practice Address - Street 1:701 N 182ND ST
Practice Address - Street 2:SUITE 101
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98133-4430
Practice Address - Country:US
Practice Address - Phone:206-542-7406
Practice Address - Fax:206-546-2266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001235152W00000X
WAOD00001604152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2130037Medicaid
WAU21767Medicare UPIN
WA0328920003Medicare NSC
WAT03077Medicare UPIN
WAAB17365Medicare ID - Type UnspecifiedPROVIDER-OTTO
WA2130037Medicaid
WAAB17366Medicare ID - Type UnspecifiedPROVIDER-KEECH