Healthcare Provider Details

I. General information

NPI: 1841232121
Provider Name (Legal Business Name): ENUMCLAW FAMILY OPTOMETRY CLINIC PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 11/11/2025
Certification Date: 11/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2726 GRIFFIN AVE STE B
ENUMCLAW WA
98022-2362
US

IV. Provider business mailing address

2726 GRIFFIN AVE STE B
ENUMCLAW WA
98022-2362
US

V. Phone/Fax

Practice location:
  • Phone: 360-825-3000
  • Fax: 360-825-8408
Mailing address:
  • Phone: 360-825-3000
  • Fax: 360-825-8408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1619
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierSH2147
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerREGENCE
# 2
Identifier1020256
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer
# 3
Identifier2016699
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer

VIII. Authorized Official

Name: ALEXANDER SHEPHERD
Title or Position: OWNER/PRES
Credential: OD
Phone: 360-825-3000