Provider Demographics
NPI:1356710933
Name:LEWIS COUNTY VISION SOURCE PC
Entity type:Organization
Organization Name:LEWIS COUNTY VISION SOURCE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:MICHELE
Authorized Official - Last Name:PADGETT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-736-4447
Mailing Address - Street 1:1805 COOKS HILL RD
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-9072
Mailing Address - Country:US
Mailing Address - Phone:360-736-4447
Mailing Address - Fax:360-807-0324
Practice Address - Street 1:1805 COOKS HILL RD
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-9072
Practice Address - Country:US
Practice Address - Phone:360-736-4447
Practice Address - Fax:360-807-0324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-24
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60236154152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty