Healthcare Provider Details

I. General information

NPI: 1972805406
Provider Name (Legal Business Name): MOBILE EYEWORKS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2010
Last Update Date: 12/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 WOOD CREEK DR
LYNDEN WA
98264-1107
US

IV. Provider business mailing address

605 WOOD CREEK DR
LYNDEN WA
98264-1107
US

V. Phone/Fax

Practice location:
  • Phone: 360-510-4432
  • Fax: 360-318-0821
Mailing address:
  • Phone: 360-510-4432
  • Fax: 360-318-0821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number602953802
License Number StateWA

VIII. Authorized Official

Name: MRS. LISA DIANE CREIGHTON
Title or Position: PRESIDENT
Credential: OPTICIAN
Phone: 360-510-4432