Provider Demographics
NPI:1124420526
Name:EYE DOCTORS NORTHWEST PLLC
Entity type:Organization
Organization Name:EYE DOCTORS NORTHWEST PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GRADY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLENBECK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:425-260-6428
Mailing Address - Street 1:17224 SE 272ND ST
Mailing Address - Street 2:STE B
Mailing Address - City:COVINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98042-4953
Mailing Address - Country:US
Mailing Address - Phone:253-528-3939
Mailing Address - Fax:
Practice Address - Street 1:17224 SE 272ND ST
Practice Address - Street 2:STE B
Practice Address - City:COVINGTON
Practice Address - State:WA
Practice Address - Zip Code:98042-4953
Practice Address - Country:US
Practice Address - Phone:253-528-3939
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-17
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3816152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U98206Medicare UPIN