Provider Demographics
NPI:1124143847
Name:ALAN H. HOMESTEAD OD PS
Entity type:Organization
Organization Name:ALAN H. HOMESTEAD OD PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:H
Authorized Official - Last Name:HOMESTEAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-767-4737
Mailing Address - Street 1:10252 16TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98146-1432
Mailing Address - Country:US
Mailing Address - Phone:206-767-4737
Mailing Address - Fax:
Practice Address - Street 1:10252 16TH AVE SW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98146-1432
Practice Address - Country:US
Practice Address - Phone:206-767-4737
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1428152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2030484Medicaid
WAGOOO 102327Medicare ID - Type Unspecified
WA2030484Medicaid