Provider Demographics
NPI:1265807382
Name:GREAT VISION NORTHWEST
Entity type:Organization
Organization Name:GREAT VISION NORTHWEST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:ONIEL
Authorized Official - Last Name:DURRANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-493-6440
Mailing Address - Street 1:14230 NE 20TH ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98007-3741
Mailing Address - Country:US
Mailing Address - Phone:425-748-1000
Mailing Address - Fax:
Practice Address - Street 1:14230 NE 20TH ST
Practice Address - Street 2:SUITE C
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007-3741
Practice Address - Country:US
Practice Address - Phone:425-748-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-01
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60189678152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty