MEDICARE: TWILIGHTVISION OPTOMETRY, CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OD60146389

General Provider Information

NPI Number	:	1255619128
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TWILIGHTVISION OPTOMETRY, CORP

Provider Business Mailing Address
First Line	:	625 BLACK LAKE BLVD SW STE 110
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98502-8603
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	625 BLACK LAKE BLVD SW STE 110
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98502-8603
Country	:	US
Telephone Number	:	360-943-1516
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. CINDY THAN
Credential	:
Telephone Number	:	360-943-1516

Provider Enumeration Date	:	07/26/2011
Last Update Date	:	10/17/2011

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