MEDICARE: NORTHWEST EYECARE NETWORK

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		WA
2	152W00000X	Optometrist	3661TX	WA

General Provider Information

NPI Number	:	1316178080
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHWEST EYECARE NETWORK

Provider Business Mailing Address
First Line	:	420 W SMITH ST
Second Line	:	SUITE 105
City	:	KENT
State	:	WA
Zip	:	98032-4423
Country	:	US
Telephone Number	:	253-867-1616
Fax Number	:	253-867-1618

Provider Business Practice Location Address
First Line	:	420 W SMITH ST
Second Line	:	SUITE 105
City	:	KENT
State	:	WA
Zip	:	98032-4423
Country	:	US
Telephone Number	:	253-867-1616
Fax Number	:	253-867-1618

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SHAUNA MAZZULLA
Credential	:	OD
Telephone Number	:	253-867-1616

Provider Enumeration Date	:	07/29/2009
Last Update Date	:	03/06/2017

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Directions to “NORTHWEST EYECARE NETWORK ” Practice Location

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