MEDICARE: EYE CARE SPECIALISTS PS

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OD00003976	WA
2	152W00000X	Optometrist	OPD-100067	ID
3	156FC0801X	Contact Lens Fitter	601269693	WA
4	207W00000X	Ophthalmology Physician	MD00014109	WA

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	CN6339	OTHER		RAILROAD MEDICARE

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0123143	OTHER	WA	LABOR & IND
4	000010006387	OTHER		REGENCE BLUE SHIELD
5	24509	OTHER		GROUP HEALTH
6	85977	OTHER	ID	BLUE CROSS
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	8927759	OTHER	WA	CRIME VICTIMS

NPI Number	:	1972514917
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYE CARE SPECIALISTS PS

Provider Business Mailing Address
First Line	:	500 PORT DR
Second Line	:
City	:	CLARKSTON
State	:	WA
Zip	:	99403-1835
Country	:	US
Telephone Number	:	509-758-8811
Fax Number	:	509-751-1188

Provider Business Practice Location Address
First Line	:	500 PORT DR
Second Line	:
City	:	CLARKSTON
State	:	WA
Zip	:	99403-1835
Country	:	US
Telephone Number	:	509-758-8811
Fax Number	:	509-751-1188

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARK T EGGLESTON
Credential	:	MD
Telephone Number	:	509-758-8811

Provider Enumeration Date	:	08/11/2006
Last Update Date	:	09/20/2011