Provider Demographics
NPI:1831753219
Name:MODERN OPTOMETRY LLC
Entity type:Organization
Organization Name:MODERN OPTOMETRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LOIS
Authorized Official - Middle Name:
Authorized Official - Last Name:FILIPELLI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:503-702-4915
Mailing Address - Street 1:3616 R ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98663-2542
Mailing Address - Country:US
Mailing Address - Phone:503-702-4915
Mailing Address - Fax:
Practice Address - Street 1:3616 R ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-2542
Practice Address - Country:US
Practice Address - Phone:503-702-4915
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-01
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8980757Medicaid