Healthcare Provider Details

I. General information

NPI: 1619225190
Provider Name (Legal Business Name): SHANI ELIZA RERECICH O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHANI ELIZA ELWOOD O.D.

II. Dates (important events)

Enumeration Date: 08/15/2012
Last Update Date: 07/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 E. JEFFERSON ST STE #202
SEATTLE WA
98122-1737
US

IV. Provider business mailing address

5021 RIPLEY LANE N #302
RENTON WA
98056-1576
US

V. Phone/Fax

Practice location:
  • Phone: 425-320-2630
  • Fax:
Mailing address:
  • Phone: 425-273-4368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD60291669
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: