Healthcare Provider Details

I. General information

NPI: 1255631016
Provider Name (Legal Business Name): BLUE MOUNTAIN EYE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2010
Last Update Date: 01/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 PENNY LN
WALLA WALLA WA
99362-4477
US

IV. Provider business mailing address

PO BOX O
WALLA WALLA WA
99362-0212
US

V. Phone/Fax

Practice location:
  • Phone: 509-540-3937
  • Fax: 509-540-3938
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207WX0108X
TaxonomyUveitis and Ocular Inflammatory Disease (Ophthalmology) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207WX0120X
TaxonomyCornea and External Diseases Specialist Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. BENJAMIN M HIGGINBOTHAM
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 509-540-3937