Provider Demographics
NPI:1932321296
Name:CORLISS OPTOMETRISTS
Entity Type:Organization
Organization Name:CORLISS OPTOMETRISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:MS
Authorized Official - First Name:CLYSTA
Authorized Official - Middle Name:C
Authorized Official - Last Name:PRIETO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-845-0587
Mailing Address - Street 1:PO BOX 1266
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-0237
Mailing Address - Country:US
Mailing Address - Phone:253-845-0585
Mailing Address - Fax:253-845-1939
Practice Address - Street 1:312 4TH ST SE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372
Practice Address - Country:US
Practice Address - Phone:253-845-0585
Practice Address - Fax:253-845-1939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA600080747152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0016684OtherDEPT OF LABOR&INDUSTRIES
WA2211704Medicaid
WA0016684OtherDEPT OF LABOR&INDUSTRIES
WA0383020001Medicare NSC