Provider Demographics
NPI:1780921304
Name:LYNDEN VISION CLINIC, PS
Entity type:Organization
Organization Name:LYNDEN VISION CLINIC, PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SWIECICKI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-354-2222
Mailing Address - Street 1:201 S 19TH ST
Mailing Address - Street 2:
Mailing Address - City:LYNDEN
Mailing Address - State:WA
Mailing Address - Zip Code:98264-1725
Mailing Address - Country:US
Mailing Address - Phone:360-354-2222
Mailing Address - Fax:360-354-0737
Practice Address - Street 1:11 BELLWETHER WAY
Practice Address - Street 2:SUITE 104
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-2957
Practice Address - Country:US
Practice Address - Phone:360-671-7107
Practice Address - Fax:360-354-0737
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LYNDEN VISION CLINIC, PS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-01-16
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3271152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0108450OtherLABOR AND INDUSTRIES
WAP00190648OtherRAILROAD MEDICARE-PALMETTO
WA2019891Medicaid
WAP00190648OtherRAILROAD MEDICARE-PALMETTO
WA2019891Medicaid