Provider Demographics
NPI:1104851690
Name:PASCO VISION CLINIC, P.S.
Entity type:Organization
Organization Name:PASCO VISION CLINIC, P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:C
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:509-547-8409
Mailing Address - Street 1:2715 W COURT ST
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-3911
Mailing Address - Country:US
Mailing Address - Phone:509-547-8409
Mailing Address - Fax:509-547-7875
Practice Address - Street 1:2715 W COURT ST
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-3911
Practice Address - Country:US
Practice Address - Phone:509-547-8409
Practice Address - Fax:509-547-3751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X
WA38152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1265729354Medicaid
WACK6046OtherRAILROAD MEDICARE
WA0056740OtherDEPT OF LABOR & INDUSTRY
WA1568661924Medicaid
WA1104851690Medicaid
WA2300028Medicaid
WA1992802656Medicaid