Basic Information
| Provider Information | |||||||||
| NPI: | 1821165911 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EYE PHYSICIANS OF OLYMPIA INC PS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | CLARUS EYE CENTRE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 345 COLLEGE ST SE | ||||||||
| Address2: | STE C | ||||||||
| City: | LACEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985031013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604563200 | ||||||||
| FaxNumber: | 3604563894 | ||||||||
| Practice Location | |||||||||
| Address1: | 345 COLLEGE ST SE | ||||||||
| Address2: | #C | ||||||||
| City: | LACEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985031013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604563200 | ||||||||
| FaxNumber: | 3604563894 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 10/06/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SCHOLES | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | NEAL | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3604563200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 7858806 | 05 | WA | MEDICAID | 7107766 | 05 | WA | MEDICAID |