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General NPI Number Information
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NPI Number | 1609889039
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Entity Type | Organization
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Legal Business Name | LIBERTY LAKE EYECARE CENTER PS
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Dates
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Enumeration Date | 08/15/2006
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Last Update Date | 09/17/2021
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Provider Practice Location Address
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Address Line | 22011 E COUNTRY VISTA DR STE 101
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City | LIBERTY LAKE
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State | WA
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Zip | 99019-5242
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Country | US
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Telephone | 154-178-6332
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Fax | 509-893-3703
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Provider Business Mailing Address
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Address Line | 2207 N MOLTER RD SUITE 100
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City | LIBERTY LAKE
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State | WA
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Zip | 99019-7571
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Country | US
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Telephone | 509-893-7574
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Fax | 509-893-3703
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Authorized Official
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Title or Position | PRESIDENT
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Name | BRET ALLEN ULRICH
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Credential | OD
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Telephone | 509-893-7574
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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 |
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License Number State |
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