Healthcare Provider Details

I. General information

NPI: 1619084910
Provider Name (Legal Business Name): SHAUN KEITH COOMBS OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 NEW VIEW CT NE
OLYMPIA WA
98506-5250
US

IV. Provider business mailing address

PO BOX 1506
CHEHALIS WA
98532-0409
US

V. Phone/Fax

Practice location:
  • Phone: 360-252-1642
  • Fax: 360-252-1646
Mailing address:
  • Phone: 360-242-3008
  • Fax: 360-807-7687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberATI2863
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPTT200
License Number StateAK
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD00003477
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: