Provider Demographics
NPI:1336370964
Name:SHELBY WICKHORST OD PC
Entity Type:Organization
Organization Name:SHELBY WICKHORST OD PC
Other - Org Name:VISION 162
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHELBY
Authorized Official - Middle Name:G
Authorized Official - Last Name:WICKHORST
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-944-1911
Mailing Address - Street 1:1901 NE 162ND AVE
Mailing Address - Street 2:SUITE D-102
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-3009
Mailing Address - Country:US
Mailing Address - Phone:360-944-1911
Mailing Address - Fax:360-944-5255
Practice Address - Street 1:1901 NE 162ND AVE
Practice Address - Street 2:SUITE D-102
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-3009
Practice Address - Country:US
Practice Address - Phone:360-944-1911
Practice Address - Fax:360-944-5255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-30
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003526152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8884140Medicare PIN