=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376730382
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEARL EYE CARE CENTER, P.S.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2007
-----------------------------------------------------
Last Update Date | 05/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5016 BRIDGEPORT WAY W
-----------------------------------------------------
City | UNIVERSITY PLACE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98467-2039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-472-1188
-----------------------------------------------------
Fax | 253-472-3594
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2505 S 38TH ST STE A108
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98409-7372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-472-1188
-----------------------------------------------------
Fax | 253-472-3594
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MICHAEL DAVID NOBLE
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 253-472-1188
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1426TX
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------