Provider Demographics
NPI:1649654633
Name:CENTRAL WASHINGTON OPTICAL, LLC
Entity type:Organization
Organization Name:CENTRAL WASHINGTON OPTICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ABEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:LI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-452-6611
Mailing Address - Street 1:3902 CREEKSIDE LOOP STE 110
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-4876
Mailing Address - Country:US
Mailing Address - Phone:509-248-5176
Mailing Address - Fax:
Practice Address - Street 1:301 N 1ST ST
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944-1465
Practice Address - Country:US
Practice Address - Phone:509-837-3845
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-20
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602255023332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1001118Medicaid