Healthcare Provider Details

I. General information

NPI: 1104112358
Provider Name (Legal Business Name): MONTESANO VISION CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2011
Last Update Date: 08/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 S MAIN ST
MONTESANO WA
98563-3709
US

IV. Provider business mailing address

118 S MAIN ST
MONTESANO WA
98563-3709
US

V. Phone/Fax

Practice location:
  • Phone: 360-249-3485
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD 3739
License Number StateWA

VIII. Authorized Official

Name: GEOFFREY F WILLS
Title or Position: MEMBER
Credential:
Phone: 360-249-3485