Healthcare Provider Details

I. General information

NPI: 1417996976
Provider Name (Legal Business Name): MARIELLE KWON O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13414 E SPRAGUE AVE
SPOKANE VALLEY WA
99216-0848
US

IV. Provider business mailing address

1215 N KING JAMES LN
LIBERTY LAKE WA
99019-9454
US

V. Phone/Fax

Practice location:
  • Phone: 509-924-2015
  • Fax: 509-921-9373
Mailing address:
  • Phone: 509-927-8784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3208
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: