Provider Demographics
NPI:1356413439
Name:FAIRHAVEN VISION CLINIC PLLC
Entity type:Organization
Organization Name:FAIRHAVEN VISION CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICAL TECHNICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:IRENE
Authorized Official - Last Name:JACOBSEN
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:360-733-1190
Mailing Address - Street 1:1207 OLD FAIRHAVEN PKWY
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-7411
Mailing Address - Country:US
Mailing Address - Phone:360-733-1190
Mailing Address - Fax:360-734-1306
Practice Address - Street 1:1207 OLD FAIRHAVEN PKWY
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-7411
Practice Address - Country:US
Practice Address - Phone:360-733-1190
Practice Address - Fax:360-734-1306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00000910152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA616790001OtherGROUP HEALTH
WA616790001OtherGROUP HEALTH
WA6254340001Medicare NSC