Basic Information
| Provider Information | |||||||||
| NPI: | 1609483429 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE VANCOUVER CLINIC INC PS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 NE 87TH AVE | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986644896 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608822778 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4500 SE COLUMBIA PALISADES DR | ||||||||
| Address2: | |||||||||
| City: | CAMAS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986078444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608822778 | ||||||||
| FaxNumber: | 3606041780 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2020 | ||||||||
| LastUpdateDate: | 09/25/2020 | ||||||||
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| AuthorizedOfficialLastName: | BARRY | ||||||||
| AuthorizedOfficialFirstName: | JULIE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 3603973352 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE VANCOUVER CLINIC INC PS | ||||||||
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| NPICertificationDate: | 09/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
ID Information
| ID | Type | State | Issuer | Description | 1046502 | 05 | WA | MEDICAID |