Healthcare Provider Details

I. General information

NPI: 1689904864
Provider Name (Legal Business Name): REVOLUTION-EYES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2010
Last Update Date: 01/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 E BROADWAY AVE
MOSES LAKE WA
98837-1717
US

IV. Provider business mailing address

215 E BROADWAY AVE
MOSES LAKE WA
98837-1717
US

V. Phone/Fax

Practice location:
  • Phone: 509-771-9342
  • Fax: 509-765-0204
Mailing address:
  • Phone: 509-771-9342
  • Fax: 509-765-0204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number602967641
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KEVIN DOUGLAS OSBORNE
Title or Position: OWNER
Credential: O.D.
Phone: 509-771-9342