Healthcare Provider Details

I. General information

NPI: 1164545612
Provider Name (Legal Business Name): CURTIS R BAXSTROM JR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 S 324TH PL
FEDERAL WAY WA
98003-8504
US

IV. Provider business mailing address

1705 S 324TH PL
FEDERAL WAY WA
98003-8504
US

V. Phone/Fax

Practice location:
  • Phone: 253-661-6005
  • Fax:
Mailing address:
  • Phone: 253-661-6005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1583
License Number StateWA

VIII. Authorized Official

Name: DR. CURTIS R. BAXSTROM
Title or Position: OWNER
Credential:
Phone: 253-661-6005