Provider Demographics
NPI:1952583536
Name:HAWKS PRAIRIE VISION CLINIC, P.S.
Entity Type:Organization
Organization Name:HAWKS PRAIRIE VISION CLINIC, P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:PIRANIO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-459-3333
Mailing Address - Street 1:2539 MARVIN RD NE SUITE B
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516
Mailing Address - Country:US
Mailing Address - Phone:360-459-3333
Mailing Address - Fax:360-459-2724
Practice Address - Street 1:2539 MARVIN RD NE STE B
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-3175
Practice Address - Country:US
Practice Address - Phone:360-459-3333
Practice Address - Fax:360-459-2724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003048305R00000X
WA305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2025922Medicaid
DF2770OtherRAILROAD MEDICARE
WA2025922Medicaid
WAGAB26488Medicare PIN