=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720279649
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YOUNGMAN VISION INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2007
-----------------------------------------------------
Last Update Date | 08/06/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5411 MILL PLAIN BLVD SUITE 28
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98661
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-693-2300
-----------------------------------------------------
Fax | 360-693-2303
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4535 NW ASPEN ST
-----------------------------------------------------
City | CAMAS
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98607-8302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-693-2300
-----------------------------------------------------
Fax | 360-693-2303
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | LORI A YOUNGMAN
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 360-693-2300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OD00003133
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------