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General NPI Number Information
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NPI Number | 1104112358
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Entity Type | Organization
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Legal Business Name | MONTESANO VISION CENTER PLLC
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Dates
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Enumeration Date | 06/27/2011
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Last Update Date | 08/25/2011
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Provider Practice Location Address
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Address Line | 118 S MAIN ST
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City | MONTESANO
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State | WA
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Zip | 98563-3709
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Country | US
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Telephone | 360-249-3485
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Fax |
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Provider Business Mailing Address
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Address Line | 118 S MAIN ST
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City | MONTESANO
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State | WA
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Zip | 98563-3709
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | GEOFFREY F WILLS
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Credential |
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Telephone | 360-249-3485
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OD 3739
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License Number State | WA
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