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General NPI Number Information
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NPI Number | 1487787511
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Entity Type | Organization
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Legal Business Name | SELAH VISION SOURCE, PLLC
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Dates
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Enumeration Date | 03/14/2007
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Last Update Date | 02/26/2008
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Provider Practice Location Address
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Address Line | 105 W ORCHARD AVE
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City | SELAH
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State | WA
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Zip | 98942-1329
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Country | US
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Telephone | 509-697-6177
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Fax | 509-697-6659
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Provider Business Mailing Address
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Address Line | 105 W ORCHARD AVE
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City | SELAH
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State | WA
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Zip | 98942-1329
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Country | US
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Telephone | 509-697-6177
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Fax | 509-697-6659
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Authorized Official
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Title or Position | PROJECTS MANAGER
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Name | MRS. NANCY S GRAF
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Credential |
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Telephone | 509-697-6177
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2610001320
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License Number State | WA
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