Provider Demographics
NPI:1801076989
Name:DES MOINES VISION CENTER INC PS
Entity type:Organization
Organization Name:DES MOINES VISION CENTER INC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:W RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:KRATTLI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:206-878-4233
Mailing Address - Street 1:21634 MARINE VIEW DR S
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:WA
Mailing Address - Zip Code:98198-6154
Mailing Address - Country:US
Mailing Address - Phone:206-878-4233
Mailing Address - Fax:206-878-5818
Practice Address - Street 1:21634 MARINE VIEW DR S
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:WA
Practice Address - Zip Code:98198-6154
Practice Address - Country:US
Practice Address - Phone:206-878-4233
Practice Address - Fax:206-878-5818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-06
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001598152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0640020001Medicare NSC