Provider Demographics
NPI:1801115191
Name:DAVID O. SCHORES OD INC PS
Entity type:Organization
Organization Name:DAVID O. SCHORES OD INC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTS MGR
Authorized Official - Prefix:MS
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-385-1093
Mailing Address - Street 1:150 CHIMACUM ROAD
Mailing Address - Street 2:PO BOX 357
Mailing Address - City:PORT HADLOCK
Mailing Address - State:WA
Mailing Address - Zip Code:98339-9774
Mailing Address - Country:US
Mailing Address - Phone:360-385-1093
Mailing Address - Fax:360-385-6843
Practice Address - Street 1:150 CHIMACUM RD
Practice Address - Street 2:
Practice Address - City:PORT HADLOCK
Practice Address - State:WA
Practice Address - Zip Code:98339-9774
Practice Address - Country:US
Practice Address - Phone:360-385-1093
Practice Address - Fax:360-385-6843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-26
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001571152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1467542985OtherRENDERING PROVIDER NPI
WADQ2827OtherRAIL ROAD MEDICARE
WAG8891340OtherRENDERING PROVIDER PTAN
WA1801115191OtherBILLING PROVIDER NPI
WA1011175Medicaid
WAG000200362OtherBILLING PROVIDER PTAN
WAG8891340OtherRENDERING PROVIDER PTAN
WADQ2827OtherRAIL ROAD MEDICARE