Healthcare Provider Details

I. General information

NPI: 1376556514
Provider Name (Legal Business Name): EYE CARE SPECIALISTS PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 09/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 PORT DR
CLARKSTON WA
99403-1835
US

IV. Provider business mailing address

500 PORT DR
CLARKSTON WA
99403-1835
US

V. Phone/Fax

Practice location:
  • Phone: 509-758-8811
  • Fax: 509-751-1188
Mailing address:
  • Phone: 509-758-8811
  • Fax: 509-751-1188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number601269693
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD00014109
License Number StateNULL

VIII. Authorized Official

Name: MR. MARK T EGGLESTON
Title or Position: PRESIDENT
Credential: MD
Phone: 509-758-8811