=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215063516
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WOODLAND EYE & VISION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2007
-----------------------------------------------------
Last Update Date | 04/08/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 COLUMBIA ST SUITE A
-----------------------------------------------------
City | WOODLAND
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98674-8491
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-225-1010
-----------------------------------------------------
Fax | 360-225-1730
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 COLUMBIA ST SUITE A
-----------------------------------------------------
City | WOODLAND
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98674-8491
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-225-1010
-----------------------------------------------------
Fax | 360-225-1730
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST-OWNER
-----------------------------------------------------
Name | JEFFREY SCOTT TACK
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 360-225-1010
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152WC0802X
-----------------------------------------------------
Taxonomy Name | Corneal and Contact Management Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152WL0500X
-----------------------------------------------------
Taxonomy Name | Low Vision Rehabilitation Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 152WP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 152WS0006X
-----------------------------------------------------
Taxonomy Name | Sports Vision Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 152WV0400X
-----------------------------------------------------
Taxonomy Name | Vision Therapy Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 152WX0102X
-----------------------------------------------------
Taxonomy Name | Occupational Vision Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------