Provider Demographics
NPI:1811052798
Name:KENNETH D. COMMON, O.D., P.S.
Entity type:Organization
Organization Name:KENNETH D. COMMON, O.D., P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:COMMON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-357-2544
Mailing Address - Street 1:625 BLACK LAKE BLVD SW
Mailing Address - Street 2:SUITE #110
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-5066
Mailing Address - Country:US
Mailing Address - Phone:360-357-2544
Mailing Address - Fax:360-357-6341
Practice Address - Street 1:625 BLACK LAKE BLVD SW
Practice Address - Street 2:SUITE #110
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-5066
Practice Address - Country:US
Practice Address - Phone:360-357-2544
Practice Address - Fax:360-357-6341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1155261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center