Provider Demographics
NPI:1427268754
Name:LYNDEN VISION CLINIC, PS
Entity type:Organization
Organization Name:LYNDEN VISION CLINIC, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MIRA
Authorized Official - Middle Name:BRIDGET
Authorized Official - Last Name:SWIECICKI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-354-2222
Mailing Address - Street 1:201 S 19TH ST
Mailing Address - Street 2:
Mailing Address - City:LYNDEN
Mailing Address - State:WA
Mailing Address - Zip Code:98264-1725
Mailing Address - Country:US
Mailing Address - Phone:360-354-2222
Mailing Address - Fax:360-354-0737
Practice Address - Street 1:201 S 19TH ST
Practice Address - Street 2:
Practice Address - City:LYNDEN
Practice Address - State:WA
Practice Address - Zip Code:98264-1725
Practice Address - Country:US
Practice Address - Phone:360-354-2222
Practice Address - Fax:360-354-0737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3271TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2022291Medicaid
WAG8851039OtherMEDICARE ID-PIN
WA0078163OtherLABOR & INDUSTRIES
WA8403LYOtherREGENCE BLUE SHIELD
WADC7970OtherRAILROAD MEDICARE-PALMETT
WAG8851039OtherMEDICARE ID-PIN
WA2022291Medicaid