=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881761351
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE CONTACT LENS AND EYECARE CLINIC, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2006
-----------------------------------------------------
Last Update Date | 02/12/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 114 E 1ST ST
-----------------------------------------------------
City | PORT ANGELES
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98362-2903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-452-2361
-----------------------------------------------------
Fax | 360-452-2362
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 114 E 1ST ST
-----------------------------------------------------
City | PORT ANGELES
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98362-2903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-452-2361
-----------------------------------------------------
Fax | 360-452-2362
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. LAWRENCE WILLIAM NIVALA
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 360-452-2361
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OD2046
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------