Provider Demographics
NPI:1720279649
Name:YOUNGMAN VISION INC
Entity Type:Organization
Organization Name:YOUNGMAN VISION INC
Other - Org Name:STATE VISION CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:A
Authorized Official - Last Name:YOUNGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-693-2300
Mailing Address - Street 1:4535 NW ASPEN ST
Mailing Address - Street 2:
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607-8302
Mailing Address - Country:US
Mailing Address - Phone:360-693-2300
Mailing Address - Fax:360-693-2303
Practice Address - Street 1:5411 MILL PLAIN BLVD
Practice Address - Street 2:SUITE 28
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661
Practice Address - Country:US
Practice Address - Phone:360-693-2300
Practice Address - Fax:360-693-2303
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:YOUNGMAN VISION INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003133152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2017689Medicaid
WA2017689Medicaid