MEDICARE: 20/20 EYECARE CENTERS INC PS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134292915
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	20/20 EYECARE CENTERS INC PS

Provider Business Mailing Address
First Line	:	PO BOX 706
Second Line	:
City	:	VASHON
State	:	WA
Zip	:	98070-5204
Country	:	US
Telephone Number	:	206-463-2020
Fax Number	:	206-463-2043

Provider Business Practice Location Address
First Line	:	17609 VASHON HWY SW
Second Line	:
City	:	VASHON
State	:	WA
Zip	:	98070-5204
Country	:	US
Telephone Number	:	206-463-2020
Fax Number	:	206-463-2049

Authorized Official
Title or Position	:	OWNER
Name	:	JON M WILLEMS
Credential	:	OD
Telephone Number	:	206-463-2020

Provider Enumeration Date	:	11/17/2006
Last Update Date	:	05/28/2008

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