=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285023713
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILLIAM PENTECOST, OD, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2015
-----------------------------------------------------
Last Update Date | 07/02/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4854 RAINIER AVE S
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98118-1742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-619-2084
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1317 E PINE ST
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98122-4021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-420-8328
-----------------------------------------------------
Fax | 206-420-5368
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | WILLIAM PENTECOST
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 206-619-2084
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OD60017743
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------