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General NPI Number Information
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NPI Number | 1124420526
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Entity Type | Organization
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Legal Business Name | EYE DOCTORS NORTHWEST PLLC
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Dates
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Enumeration Date | 09/17/2014
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Last Update Date | 09/17/2014
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Provider Practice Location Address
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Address Line | 17224 SE 272ND ST STE B
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City | COVINGTON
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State | WA
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Zip | 98042-4953
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Country | US
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Telephone | 253-528-3939
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Fax |
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Provider Business Mailing Address
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Address Line | 17224 SE 272ND ST STE B
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City | COVINGTON
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State | WA
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Zip | 98042-4953
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Country | US
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Telephone | 253-528-3939
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | GRADY HOLLENBECK
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Credential | O.D.
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Telephone | 425-260-6428
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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 | 3816
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License Number State | WA
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