Healthcare Provider Details

I. General information

NPI: 1710048772
Provider Name (Legal Business Name): EYE CARE SPECIALISTS PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 09/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 SE BISHOP BLVD STE 110
PULLMAN WA
99163-5517
US

IV. Provider business mailing address

500 PORT DR
CLARKSTON WA
99403-1835
US

V. Phone/Fax

Practice location:
  • Phone: 509-334-1661
  • Fax: 509-334-1788
Mailing address:
  • Phone: 509-758-8811
  • Fax: 509-751-1188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD00003976
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code156FC0801X
TaxonomyContact Lens Fitter
License Number601269693
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number601269693
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD00014109
License Number StateWA

VII. Legacy identifiers

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

# 1
Identifier000010006387
Identifier TypeOTHER
Identifier State
Identifier IssuerREGENCE BLUE SHIELD
# 2
Identifier805350600
Identifier TypeMEDICAID
Identifier StateID
Identifier Issuer
# 3
Identifier8927759
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerCRIME VICTIMS
# 4
Identifier85977
Identifier TypeOTHER
Identifier StateID
Identifier IssuerBLUE CROSS
# 5
Identifier0123143
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerLABOR & IND
# 6
Identifier24509
Identifier TypeOTHER
Identifier State
Identifier IssuerGROUP HEALTH
# 7
Identifier7088859
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer

VIII. Authorized Official

Name: MR. MARK T EGGLESTON
Title or Position: PRESIDENT
Credential: MD
Phone: 509-758-8811