Provider Demographics
NPI:1194094490
Name:MILL CREEK EYE AND CONTACT LENS CLINIC, INC.
Entity type:Organization
Organization Name:MILL CREEK EYE AND CONTACT LENS CLINIC, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:MASATO
Authorized Official - Last Name:ARIMA
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:425-745-5650
Mailing Address - Street 1:15808 MILL CREEK BLVD
Mailing Address - Street 2:SUITE #110
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-1500
Mailing Address - Country:US
Mailing Address - Phone:425-745-5650
Mailing Address - Fax:425-337-1342
Practice Address - Street 1:15808 MILL CREEK BLVD
Practice Address - Street 2:SUITE #110
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-1500
Practice Address - Country:US
Practice Address - Phone:425-745-5650
Practice Address - Fax:425-337-1342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-15
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1409152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2011344Medicaid
WA=========OtherCHAMPUS
WA2011344Medicaid