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General NPI Number Information
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NPI Number | 1477542439
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Entity Type | Organization
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Legal Business Name | PACIFIC EYECARE OF POULISBO PS
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Dates
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Enumeration Date | 10/20/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 20669 BOND RD NE STE 100
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City | POULSBO
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State | WA
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Zip | 98370
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Country | US
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Telephone | 360-779-2020
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Fax | 360-779-3093
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Provider Business Mailing Address
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Address Line | 20669 BOND RD NE STE 100
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City | POULSBO
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State | WA
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Zip | 98370
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Country | US
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Telephone | 360-779-2020
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Fax | 360-779-3093
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Authorized Official
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Title or Position | MD/OWNER
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Name | DAVID SC OMORCHOC
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Credential | MD
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Telephone | 360-779-2020
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | MD00029555
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License Number State | WA
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