=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790907491
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EAST VANCOUVER EYE CLINIC P.S.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2007
-----------------------------------------------------
Last Update Date | 06/15/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6680 NE 159TH AVE. SUITE # 102
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98682-8830
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-449-3937
-----------------------------------------------------
Fax | 360-449-3094
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6680 NE 159TH AVE. SUITE # 102
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98682-8830
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-449-3937
-----------------------------------------------------
Fax | 360-449-3094
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. GARY ALAN COLE
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 360-449-3937
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OD00003402
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------