=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003215328
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CASCADE PACIFIC EYECARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2014
-----------------------------------------------------
Last Update Date | 08/22/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1314 72ND ST E SUITE D
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98404-3343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-531-5535
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1314 72ND ST E SUITE D
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98404-3343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | SHELBY ROBINSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 253-531-5535
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 60471254
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------