=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770564445
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROFESSIONAL VISION SERVICES, PS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2005
-----------------------------------------------------
Last Update Date | 04/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4620 PACIFIC AVE
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98408-7738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-473-3443
-----------------------------------------------------
Fax | 253-473-7127
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4620 PACIFIC AVE
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98408-7738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-473-3443
-----------------------------------------------------
Fax | 253-473-7127
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. HAROLD L. BIRCUMSHAW
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 253-473-3443
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152WC0802X
-----------------------------------------------------
Taxonomy Name | Corneal and Contact Management Optometrist
-----------------------------------------------------
License Number | 1349
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------