Provider Demographics
NPI:1982883302
Name:EAGLE EYE VISION CARE PS
Entity Type:Organization
Organization Name:EAGLE EYE VISION CARE PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KERRI
Authorized Official - Middle Name:W
Authorized Official - Last Name:SCARBROUGH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:425-398-1862
Mailing Address - Street 1:17320 135TH AVE NE STE D
Mailing Address - Street 2:
Mailing Address - City:WOODINVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98072-8565
Mailing Address - Country:US
Mailing Address - Phone:425-398-1862
Mailing Address - Fax:
Practice Address - Street 1:17320 135TH AVE NE STE D
Practice Address - Street 2:
Practice Address - City:WOODINVILLE
Practice Address - State:WA
Practice Address - Zip Code:98072-8565
Practice Address - Country:US
Practice Address - Phone:425-398-1862
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWA1675TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2023877Medicaid
WAG000109479Medicare PIN