Healthcare Provider Details

I. General information

NPI: 1639846595
Provider Name (Legal Business Name): TAMIKO ESCALANTE OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2021
Last Update Date: 12/23/2021
Certification Date: 12/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 COOPER POINT RD SW
OLYMPIA WA
98502-5735
US

IV. Provider business mailing address

1625 COOPER POINT RD SW
OLYMPIA WA
98502-5735
US

V. Phone/Fax

Practice location:
  • Phone: 360-357-6683
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD61211416
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: