Healthcare Provider Details

I. General information

NPI: 1447323811
Provider Name (Legal Business Name): DAVENPORT VISION CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 10/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 8TH ST
DAVENPORT WA
99122
US

IV. Provider business mailing address

PO BOX 27
DAVENPORT WA
99122-0027
US

V. Phone/Fax

Practice location:
  • Phone: 509-725-2000
  • Fax: 509-725-4231
Mailing address:
  • Phone: 509-725-2000
  • Fax: 509-725-4231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0D00003248
License Number StateWA

VIII. Authorized Official

Name: STACIE R NICHOLS
Title or Position: OWNER
Credential: OD
Phone: 509-725-2000