Healthcare Provider Details

I. General information

NPI: 1043321508
Provider Name (Legal Business Name): CENTRAL WASHINGTON OPTICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 01/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3902 CREEKSIDE LOOP SUITE 110
YAKIMA WA
98902-4876
US

IV. Provider business mailing address

3902 CREEKSIDE LOOP SUITE 110
YAKIMA WA
98902-4876
US

V. Phone/Fax

Practice location:
  • Phone: 509-248-5176
  • Fax: 509-248-0621
Mailing address:
  • Phone: 509-248-5176
  • Fax: 509-248-0621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberDO00001728
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number602255023
License Number StateWA

VIII. Authorized Official

Name: DONNA HATCH
Title or Position: MANAGER
Credential:
Phone: 509-248-5176