Healthcare Provider Details

I. General information

NPI: 1750068540
Provider Name (Legal Business Name): AMANDA HOVER LDO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2023
Last Update Date: 07/03/2023
Certification Date: 07/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 FREEWAY DR
MOUNT VERNON WA
98273-5445
US

IV. Provider business mailing address

2301 FREEWAY DR
MOUNT VERNON WA
98273-5445
US

V. Phone/Fax

Practice location:
  • Phone: 360-428-5033
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberDO60338142
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: