Healthcare Provider Details

I. General information

NPI: 1457358657
Provider Name (Legal Business Name): NILS W. OHLSEN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 10/09/2023
Certification Date: 10/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15727 E BROADWAY AVE
SPOKANE VALLEY WA
99037-9544
US

IV. Provider business mailing address

PO BOX 581
LIBERTY LAKE WA
99019-0581
US

V. Phone/Fax

Practice location:
  • Phone: 509-926-0667
  • Fax: 509-922-9849
Mailing address:
  • Phone: 509-928-6922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT-002651
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG004078
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODP-100587
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT-OPT-LIC-4613
License Number StateMT
# 5
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1079
License Number StateNH
# 6
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3589
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: