Healthcare Provider Details

I. General information

NPI: 1659555860
Provider Name (Legal Business Name): COLONIAL OPTICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/24/2007
Last Update Date: 04/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12911 120TH AVE NE SUITE C-80
KIRKLAND WA
98034-3027
US

IV. Provider business mailing address

12911 120TH AVE NE SUITE C-80
KIRKLAND WA
98034-3027
US

V. Phone/Fax

Practice location:
  • Phone: 425-821-1820
  • Fax:
Mailing address:
  • Phone: 425-821-1820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD00003740
License Number StateWA

VIII. Authorized Official

Name: MR. TODD MICHAEL JUBIE
Title or Position: OWNER
Credential:
Phone: 425-821-1820