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General NPI Number Information
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NPI Number | 1356710933
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Entity Type | Organization
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Legal Business Name | LEWIS COUNTY VISION SOURCE PC
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Dates
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Enumeration Date | 09/24/2015
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Last Update Date | 12/23/2015
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Provider Practice Location Address
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Address Line | 1805 COOKS HILL RD
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City | CENTRALIA
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State | WA
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Zip | 98531-9072
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Country | US
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Telephone | 360-736-4447
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Fax | 360-807-0324
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Provider Business Mailing Address
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Address Line | 1805 COOKS HILL RD
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City | CENTRALIA
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State | WA
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Zip | 98531-9072
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Country | US
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Telephone | 360-736-4447
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Fax | 360-807-0324
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Authorized Official
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Title or Position | OWNER
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Name | KELLY MICHELE PADGETT
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Credential | OD
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Telephone | 360-736-4447
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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 | 60236154
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License Number State | WA
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