=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376911974
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ERIC VO OD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2015
-----------------------------------------------------
Last Update Date | 01/24/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4401 4TH AVE S
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98134-2311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-975-9392
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4401 4TH AVE S
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98134-2311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-975-9392
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ERIC VO
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 626-975-9392
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | WA60234896
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------