=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477581080
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NIDA GOULDING O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2006
-----------------------------------------------------
Last Update Date | 12/20/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 N MERIDIAN
-----------------------------------------------------
City | PUYALLUP
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98371-4403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-848-6400
-----------------------------------------------------
Fax | 360-579-0749
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 633
-----------------------------------------------------
City | LANGLEY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98260-0633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-281-9272
-----------------------------------------------------
Fax | 360-579-0749
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 4049
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------