Healthcare Provider Details

I. General information

NPI: 1497415087
Provider Name (Legal Business Name): DW FAMILY EYE CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2021
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 HOSPITAL WAY
BREWSTER WA
98812-0015
US

IV. Provider business mailing address

PO BOX 783
HAYDEN ID
83835-0783
US

V. Phone/Fax

Practice location:
  • Phone: 509-689-2342
  • Fax: 509-689-9207
Mailing address:
  • Phone: 509-689-2342
  • Fax: 509-689-9207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: BRANDON WATSON
Title or Position: OPTOMETRIST
Credential: OD
Phone: 208-305-9694