Provider Demographics
NPI:1457539884
Name:DUPONT FAMILY VISION CLINIC, LLC
Entity type:Organization
Organization Name:DUPONT FAMILY VISION CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:SHAFFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-912-0900
Mailing Address - Street 1:1570 WILMINGTON DR STE 160
Mailing Address - Street 2:
Mailing Address - City:DUPONT
Mailing Address - State:WA
Mailing Address - Zip Code:98327-8773
Mailing Address - Country:US
Mailing Address - Phone:253-912-0900
Mailing Address - Fax:
Practice Address - Street 1:1570 WILMINGTON DR STE 160
Practice Address - Street 2:
Practice Address - City:DUPONT
Practice Address - State:WA
Practice Address - Zip Code:98327-8773
Practice Address - Country:US
Practice Address - Phone:253-912-0900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1618TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAY13214Medicare UPIN
WA5949360001Medicare NSC
WAG8804971Medicare PIN