Healthcare Provider Details

I. General information

NPI: 1003970823
Provider Name (Legal Business Name): BRENT CHIN OD INC PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 06/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32717 1ST AVE S STE.6
FEDERAL WAY WA
98003-5758
US

IV. Provider business mailing address

32717 1ST AVE S STE.6
FEDERAL WAY WA
98003-5758
US

V. Phone/Fax

Practice location:
  • Phone: 253-838-5428
  • Fax: 253-838-0875
Mailing address:
  • Phone: 253-838-5428
  • Fax: 253-838-0875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOD00003778TX
License Number StateWA

VIII. Authorized Official

Name: BRENT CHIN
Title or Position: PRESIDENT
Credential:
Phone: 253-838-5428