Provider Demographics
NPI:1700945979
Name:EDMONDS OPTICIAN OF SPRING VALLEY INC.
Entity Type:Organization
Organization Name:EDMONDS OPTICIAN OF SPRING VALLEY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:TATE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-237-0070
Mailing Address - Street 1:4900 MASSACHUSETTS AVE NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20016-4358
Mailing Address - Country:US
Mailing Address - Phone:202-237-0070
Mailing Address - Fax:202-237-9187
Practice Address - Street 1:4900 MASSACHUSETTS AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20016-4358
Practice Address - Country:US
Practice Address - Phone:202-237-0070
Practice Address - Fax:202-237-9187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC3888110001OtherSUPPLIER NUMBER