Provider Demographics
NPI:1811986870
Name:PACIFIC EYE CARE OF POULSBO PS
Entity type:Organization
Organization Name:PACIFIC EYE CARE OF POULSBO PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:JC
Authorized Official - Last Name:OMORCHOE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-779-2020
Mailing Address - Street 1:20669 BOND RD NE
Mailing Address - Street 2:STE 100
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-6525
Mailing Address - Country:US
Mailing Address - Phone:360-779-3093
Mailing Address - Fax:360-779-2020
Practice Address - Street 1:1135 BETHEL AVE
Practice Address - Street 2:
Practice Address - City:PT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-3125
Practice Address - Country:US
Practice Address - Phone:360-895-2020
Practice Address - Fax:360-874-0048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00029555332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2025633Medicaid
0376550005Medicare ID - Type Unspecified
WA2025633Medicaid