1154657955 NPI number — TWIN RIVER VISION, INC.

Table of content: (NPI 1154657955)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154657955 NPI number — TWIN RIVER VISION, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TWIN RIVER VISION, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154657955
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 375
Provider Second Line Business Mailing Address:
306 5TH STREET
Provider Business Mailing Address City Name:
CLARKSTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99403-0375
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-758-9470
Provider Business Mailing Address Fax Number:
509-758-9478

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
306 5TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLARKSTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-758-9470
Provider Business Practice Location Address Fax Number:
509-758-9478
Provider Enumeration Date:
10/29/2009

Additional Information

Authorized Official

Authorized Official Last Name:
PYLE
Authorized Official First Name:
MARK
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT/OPTOMETRIST
Authorized Official Telephone Number:
509-758-9470

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OD60110615 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com