Provider Demographics
NPI:1386923654
Name:OVERLAKE VISION CLINIC, LLC
Entity type:Organization
Organization Name:OVERLAKE VISION CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIC PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MITSUOKA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:310-487-2783
Mailing Address - Street 1:15902 NE 27TH PL
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98008-2248
Mailing Address - Country:US
Mailing Address - Phone:310-487-2783
Mailing Address - Fax:
Practice Address - Street 1:2200 148TH AVE NE
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-5524
Practice Address - Country:US
Practice Address - Phone:425-644-6581
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-04
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60226320261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center