Basic Information
| Provider Information | |||||||||
| NPI: | 1033356035 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRATLIE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | OPTICIAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 820 N CHELAN AVE | ||||||||
| Address2: | |||||||||
| City: | WENATCHEE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988012028 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 916 KOALA AVE | ||||||||
| Address2: | |||||||||
| City: | OMAK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988419576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098261800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2009 | ||||||||
| LastUpdateDate: | 03/23/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156FX1800X | DO00000500 | WA | Y | Eye and Vision Services Providers | Technician/Technologist | Optician |
ID Information
| ID | Type | State | Issuer | Description | 0244743 | 01 | WA | L&I | OTHER |