Provider Demographics
NPI:1336267152
Name:ELLENSBURG VISION CLINIC, PS, INC
Entity Type:Organization
Organization Name:ELLENSBURG VISION CLINIC, PS, INC
Other - Org Name:FAMILY EYE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BYRON
Authorized Official - Middle Name:E
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:509-925-9873
Mailing Address - Street 1:PO BOX 688
Mailing Address - Street 2:
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926-0688
Mailing Address - Country:US
Mailing Address - Phone:509-925-9873
Mailing Address - Fax:509-962-1639
Practice Address - Street 1:301 E 2ND AVE
Practice Address - Street 2:
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-3315
Practice Address - Country:US
Practice Address - Phone:509-925-9873
Practice Address - Fax:509-962-1639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA000788TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1447267224OtherNPI NUMBER
WA1841204260OtherNPI NUMBER