Provider Demographics
NPI:1396829123
Name:ALDERWOOD VISION CLINIC, INC. P.S.
Entity type:Organization
Organization Name:ALDERWOOD VISION CLINIC, INC. P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:DEREK
Authorized Official - Last Name:HYDE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:425-771-2662
Mailing Address - Street 1:18631 ALDERWOOD MALL PKWY STE 105
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98037-8057
Mailing Address - Country:US
Mailing Address - Phone:425-771-2662
Mailing Address - Fax:425-670-2333
Practice Address - Street 1:18631 ALDERWOOD MALL PKWY STE 105
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98037-8057
Practice Address - Country:US
Practice Address - Phone:425-771-2662
Practice Address - Fax:425-670-2333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA600387275152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2001873Medicaid
WA0291060001Medicare NSC
WA2001873Medicaid