Healthcare Provider Details

I. General information

NPI: 1316039373
Provider Name (Legal Business Name): ALEX ILYIN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 11/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 WEST MAIN STREET
EVERSON WA
98247
US

IV. Provider business mailing address

PO BOX 853
EVERSON WA
98247-0853
US

V. Phone/Fax

Practice location:
  • Phone: 360-966-0445
  • Fax:
Mailing address:
  • Phone: 360-966-0445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD00003776
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: