=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396839197
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHWEST OPTICAL VISION CENTER INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2006
-----------------------------------------------------
Last Update Date | 05/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7501 BRIDGEPORT WAY W STE C
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98499-2423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-572-5498
-----------------------------------------------------
Fax | 253-409-2841
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7501 BRIDGEPORT WAY W STE C
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98499-2423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-572-5498
-----------------------------------------------------
Fax | 253-409-2841
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTICIAN/PRESIDENT
-----------------------------------------------------
Name | MRS. DOROTHY MAY JACKL
-----------------------------------------------------
Credential | L.D.O
-----------------------------------------------------
Telephone | 253-572-5498
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | DO00001821
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------