Provider Demographics
NPI:1932227154
Name:SAN JUANS VISION CARE P.S.
Entity Type:Organization
Organization Name:SAN JUANS VISION CARE P.S.
Other - Org Name:SAN JUANS VISION SOURCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:T
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-376-5310
Mailing Address - Street 1:PO BOX 181
Mailing Address - Street 2:
Mailing Address - City:EASTSOUND
Mailing Address - State:WA
Mailing Address - Zip Code:98245
Mailing Address - Country:US
Mailing Address - Phone:360-376-5310
Mailing Address - Fax:866-393-7127
Practice Address - Street 1:1286 SUITE 106 B MT BAKER ROAD
Practice Address - Street 2:
Practice Address - City:EASTSOUND
Practice Address - State:WA
Practice Address - Zip Code:98245
Practice Address - Country:US
Practice Address - Phone:360-376-5310
Practice Address - Fax:866-393-7127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001839261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG115000519Medicare ID - Type Unspecified
WAU03038Medicare UPIN