Provider Demographics
NPI:1740483056
Name:OLYMPIC PEAKS OPTICAL
Entity type:Organization
Organization Name:OLYMPIC PEAKS OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:NORMAN
Authorized Official - Last Name:HOLDREN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-377-3703
Mailing Address - Street 1:2655 WHEATON WAY
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310
Mailing Address - Country:US
Mailing Address - Phone:360-377-3703
Mailing Address - Fax:360-377-9469
Practice Address - Street 1:1740 POTTERY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366
Practice Address - Country:US
Practice Address - Phone:360-895-0847
Practice Address - Fax:360-876-5771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA0025209MD0003187332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0317830001Medicare NSC