Provider Demographics
NPI:1700277803
Name:VINTAGE OPTICAL LLC
Entity Type:Organization
Organization Name:VINTAGE OPTICAL LLC
Other - Org Name:KITSAP OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:FAIRBANKS
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:360-698-1685
Mailing Address - Street 1:3260 NW MOUNT VINTAGE WAY
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-6000
Mailing Address - Country:US
Mailing Address - Phone:360-698-1685
Mailing Address - Fax:360-698-1763
Practice Address - Street 1:3260 NW MOUNT VINTAGE WAY
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-6000
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:2015-02-10
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty