MEDICARE: SELAH VISION SOURCE, PLLC

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	2610001320	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	17129	OTHER	WA	L & I
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	8905978	OTHER	WA	L & I CRIME VICTIMS
4	C 600 340 4768	OTHER	WA	UBI #

General Provider Information

NPI Number	:	1487787511
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SELAH VISION SOURCE, PLLC

Provider Business Mailing Address
First Line	:	105 W ORCHARD AVE
Second Line	:
City	:	SELAH
State	:	WA
Zip	:	98942-1329
Country	:	US
Telephone Number	:	509-697-6177
Fax Number	:	509-697-6659

Provider Business Practice Location Address
First Line	:	105 W ORCHARD AVE
Second Line	:
City	:	SELAH
State	:	WA
Zip	:	98942-1329
Country	:	US
Telephone Number	:	509-697-6177
Fax Number	:	509-697-6659

Authorized Official
Title or Position	:	PROJECTS MANAGER
Name	:	MRS. NANCY S GRAF
Credential	:
Telephone Number	:	509-697-6177

Provider Enumeration Date	:	03/14/2007
Last Update Date	:	02/26/2008

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Directions to “SELAH VISION SOURCE, PLLC ” Practice Location

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