Provider Demographics
NPI:1831308790
Name:MEDNIC PC
Entity type:Organization
Organization Name:MEDNIC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:R
Authorized Official - Last Name:MEDESKI-NICACIO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-694-6541
Mailing Address - Street 1:912 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-3136
Mailing Address - Country:US
Mailing Address - Phone:360-694-6541
Mailing Address - Fax:360-696-2578
Practice Address - Street 1:912 MAIN ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660-3136
Practice Address - Country:US
Practice Address - Phone:360-694-6541
Practice Address - Fax:360-696-2578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001808152W00000X
WAOD00001999152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2023141Medicaid
WA2023133Medicaid
WA2023133Medicaid
WA4148630001Medicare NSC
WAGAB13044Medicare PIN
WAU29339Medicare UPIN
WA4148630002Medicare NSC