MEDICARE: LAKE STEVENS VISION CLINIC, INC

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	1315TX	WA

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	:	1275666042
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE STEVENS VISION CLINIC, INC

Provider Business Mailing Address
First Line	:	515 STATE ROUTE 9 NE STE 104
Second Line	:
City	:	LAKE STEVENS
State	:	WA
Zip	:	98258-8523
Country	:	US
Telephone Number	:	425-334-4016
Fax Number	:	425-334-4017

Provider Business Practice Location Address
First Line	:	515 STATE ROUTE 9 NE STE 104
Second Line	:
City	:	LAKE STEVENS
State	:	WA
Zip	:	98258-8523
Country	:	US
Telephone Number	:	425-334-4016
Fax Number	:	425-334-4017

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RODNEY ALAN WINDHORST
Credential	:	O.D.
Telephone Number	:	425-334-4016

Provider Enumeration Date	:	03/13/2007
Last Update Date	:	11/25/2008

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