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General NPI Number Information
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NPI Number | 1336370964
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Entity Type | Organization
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Legal Business Name | SHELBY WICKHORST OD PC
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Dates
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Enumeration Date | 07/30/2009
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Last Update Date | 09/29/2014
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Provider Practice Location Address
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Address Line | 1901 NE 162ND AVE SUITE D-102
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City | VANCOUVER
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State | WA
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Zip | 98684-3009
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Country | US
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Telephone | 360-944-1911
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Fax | 360-944-5255
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Provider Business Mailing Address
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Address Line | 1901 NE 162ND AVE SUITE D-102
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City | VANCOUVER
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State | WA
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Zip | 98684-3009
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Country | US
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Telephone | 360-944-1911
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Fax | 360-944-5255
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Authorized Official
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Title or Position | OWNER, DOCTOR
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Name | DR. SHELBY G. WICKHORST
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Credential | OD
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Telephone | 360-944-1911
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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 | OD00003526
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License Number State | WA
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