Healthcare Provider Details

I. General information

NPI: 1972851020
Provider Name (Legal Business Name): SPOKANE OPTICAL COMPANY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2012
Last Update Date: 01/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16201 E INDIANA AVE 5000
SPOKANE VALLEY WA
99216-2830
US

IV. Provider business mailing address

16201 E INDIANA AVE 5000
SPOKANE VALLEY WA
99216-2830
US

V. Phone/Fax

Practice location:
  • Phone: 509-924-7271
  • Fax: 509-928-7802
Mailing address:
  • Phone: 509-924-7271
  • Fax: 509-928-7802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number602617024
License Number StateWA

VIII. Authorized Official

Name: RANDALL K JACOBSON
Title or Position: PHYSICIAN
Credential: MD
Phone: 509-456-0107