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General NPI Number Information
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NPI Number | 1972989069
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Entity Type | Organization
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Legal Business Name | SHORELINE EYECARE PC
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Dates
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Enumeration Date | 07/31/2015
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Last Update Date | 07/31/2015
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Provider Practice Location Address
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Address Line | 18021 15TH AVE NE SUITE 100
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City | SHORELINE
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State | WA
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Zip | 98155-3806
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Country | US
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Telephone | 206-367-8883
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Fax | 206-913-2915
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Provider Business Mailing Address
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Address Line | 2558 76TH AVE SE APT 371
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City | MERCER ISLAND
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State | WA
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Zip | 98040-3785
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Country | US
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Telephone | 314-541-6529
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Fax |
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. ERIKA TYDOR
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Credential | O.D.
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Telephone | 314-541-6529
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 60293866
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License Number State | WA
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