Provider Demographics
NPI:1992986327
Name:GARLAND VISION SOURCE, INC.
Entity type:Organization
Organization Name:GARLAND VISION SOURCE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTS AND INSURANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-327-9505
Mailing Address - Street 1:521 W GARLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99205-2954
Mailing Address - Country:US
Mailing Address - Phone:509-327-9505
Mailing Address - Fax:509-325-3277
Practice Address - Street 1:521 W GARLAND AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99205-2954
Practice Address - Country:US
Practice Address - Phone:509-327-9505
Practice Address - Fax:509-325-3277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3101TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U19693OtherUPIN
E08254OtherREGENCE BLUESHIELD RIDER
WA0145801OtherLABOR & INDUSTRIES
WA2024560Medicaid
WA2024560Medicaid
WA0145801OtherLABOR & INDUSTRIES
E08254OtherREGENCE BLUESHIELD RIDER