Healthcare Provider Details

I. General information

NPI: 1154478014
Provider Name (Legal Business Name): BONNEY LAKE OPTICAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19205 STATE ROUTE 410 E
BONNEY LAKE WA
98391-6305
US

IV. Provider business mailing address

PO BOX 2139
ORTING WA
98360-2139
US

V. Phone/Fax

Practice location:
  • Phone: 253-826-9156
  • Fax: 253-826-9158
Mailing address:
  • Phone: 253-826-9156
  • Fax: 253-826-9158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number1641
License Number StateWA

VIII. Authorized Official

Name: SEAN CUDAHY
Title or Position: CFO
Credential: OD
Phone: 253-750-8135