MEDICARE: SPOKANE OPTICAL COMPANY LLC

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	332H00000X	Eyewear Supplier	602617024	WA

General Provider Information

NPI Number	:	1972851020
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPOKANE OPTICAL COMPANY LLC

Provider Business Mailing Address
First Line	:	16201 E INDIANA AVE
Second Line	:	5000
City	:	SPOKANE VALLEY
State	:	WA
Zip	:	99216-2830
Country	:	US
Telephone Number	:	509-924-7271
Fax Number	:	509-928-7802

Provider Business Practice Location Address
First Line	:	16201 E INDIANA AVE
Second Line	:	5000
City	:	SPOKANE VALLEY
State	:	WA
Zip	:	99216-2830
Country	:	US
Telephone Number	:	509-924-7271
Fax Number	:	509-928-7802

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	RANDALL K JACOBSON
Credential	:	MD
Telephone Number	:	509-456-0107

Provider Enumeration Date	:	08/21/2012
Last Update Date	:	01/20/2015

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Directions to “SPOKANE OPTICAL COMPANY LLC ” Practice Location

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