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General NPI Number Information
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NPI Number | 1811919871
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Entity Type | Individual
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Provider Name | PENPORN VONGSVIVUT RECK MD
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Gender | Female
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Dates
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Enumeration Date | 07/25/2006
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Last Update Date | 04/10/2025
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Provider Practice Location Address
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Address Line | 345 COLLEGE ST SE STE C
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City | LACEY
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State | WA
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Zip | 98503-1014
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Country | US
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Telephone | 360-456-3200
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Fax | 360-456-3894
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Provider Business Mailing Address
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Address Line | 345 COLLEGE ST SE SUITE C
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City | LACEY
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State | WA
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Zip | 98503-1014
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Country | US
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Telephone | 360-456-3200
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Fax | 360-456-3894
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207WX0107X
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Taxonomy Name | Retina Specialist (Ophthalmology) Physician
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License Number | MD00049407
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | MD00049407
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License Number State | WA
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