Provider Demographics
NPI:1669545075
Name:KITSAP OPTICAL INC
Entity type:Organization
Organization Name:KITSAP OPTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:LORRAINE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:360-479-6301
Mailing Address - Street 1:3260 N.W. MOUNT VINTAGE WAY
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383
Mailing Address - Country:US
Mailing Address - Phone:360-698-1685
Mailing Address - Fax:360-698-1763
Practice Address - Street 1:3260 N.W. MOUNT VINTAGE WAY
Practice Address - Street 2:SU
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383
Practice Address - Country:US
Practice Address - Phone:360-698-1685
Practice Address - Fax:360-698-1763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAC600620889332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2077600Medicaid
WA2077600Medicaid