Provider Demographics
NPI:1962690701
Name:TWIN HARBORS EYE CENTER PS
Entity type:Organization
Organization Name:TWIN HARBORS EYE CENTER PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUYLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-533-2020
Mailing Address - Street 1:207 S CHEHALIS ST
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-2945
Mailing Address - Country:US
Mailing Address - Phone:360-533-2020
Mailing Address - Fax:360-533-1978
Practice Address - Street 1:207 S CHEHALIS ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-2945
Practice Address - Country:US
Practice Address - Phone:360-533-2020
Practice Address - Fax:360-533-1978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60310191152W00000X
WAMD28344207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB04443Medicare PIN