Provider Demographics
NPI:1215063516
Name:WOODLAND EYE & VISION
Entity type:Organization
Organization Name:WOODLAND EYE & VISION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:TACK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-225-1010
Mailing Address - Street 1:500 COLUMBIA ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:WOODLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98674-8491
Mailing Address - Country:US
Mailing Address - Phone:360-225-1010
Mailing Address - Fax:360-225-1730
Practice Address - Street 1:500 COLUMBIA ST
Practice Address - Street 2:SUITE A
Practice Address - City:WOODLAND
Practice Address - State:WA
Practice Address - Zip Code:98674-8491
Practice Address - Country:US
Practice Address - Phone:360-225-1010
Practice Address - Fax:360-225-1730
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LONGVIEW EYE & VISION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-23
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Single Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Single Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
No152WX0102XEye and Vision Services ProvidersOptometristOccupational VisionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA410024013OtherRAILROAD MEDICARE
WA2021772Medicaid
WA410024013OtherRAILROAD MEDICARE
WAGAB05769Medicare PIN