Provider Demographics
NPI:1962544692
Name:OLYMPIA VISION CLINIC AND CONTACT LENS CENTER, PLLC
Entity type:Organization
Organization Name:OLYMPIA VISION CLINIC AND CONTACT LENS CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:LEROY
Authorized Official - Last Name:TOSLAND
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-357-6683
Mailing Address - Street 1:1625 COOPER POINT RD SW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-5735
Mailing Address - Country:US
Mailing Address - Phone:360-357-6683
Mailing Address - Fax:360-754-0482
Practice Address - Street 1:1625 COOPER POINT RD SW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-5735
Practice Address - Country:US
Practice Address - Phone:360-357-6683
Practice Address - Fax:360-754-0482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2031011Medicaid
WA4576KOOtherREGENCE RIDER NUMBER
WA201448Medicaid
WATO5614OtherREGENCE RIDER NUMBER
WA8855532Medicare ID - Type Unspecified
WATO5614OtherREGENCE RIDER NUMBER
WATO2870Medicare UPIN
WA201448Medicaid