Provider Demographics
NPI:1336210483
Name:FEDERAL WAY VISION CENTER
Entity Type:Organization
Organization Name:FEDERAL WAY VISION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-838-5428
Mailing Address - Street 1:32717 1ST AVE S
Mailing Address - Street 2:SUITE 6
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-5758
Mailing Address - Country:US
Mailing Address - Phone:253-838-5428
Mailing Address - Fax:253-838-0875
Practice Address - Street 1:32717 1ST AVE S
Practice Address - Street 2:SUITE 6
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-5758
Practice Address - Country:US
Practice Address - Phone:253-838-5428
Practice Address - Fax:253-838-0875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001448TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2005999Medicaid
WA2005999Medicaid