=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548713563
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AESTHETIC EYE ASSOCIATES PS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2016
-----------------------------------------------------
Last Update Date | 07/29/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 625 4TH AVE STE 301
-----------------------------------------------------
City | KIRKLAND
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98033-9028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-216-7200
-----------------------------------------------------
Fax | 425-216-7272
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 625 4TH AVE STE 301
-----------------------------------------------------
City | KIRKLAND
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98033-9028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-216-7200
-----------------------------------------------------
Fax | 425-216-7272
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | JANET JORDAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 425-216-7200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QS0132X
-----------------------------------------------------
Taxonomy Name | Ophthalmologic Surgery Clinic/Center
-----------------------------------------------------
License Number | ASF.FS.60574719
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | ASF.FS.60574719
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------