Provider Demographics
NPI:1487787511
Name:SELAH VISION SOURCE, PLLC
Entity type:Organization
Organization Name:SELAH VISION SOURCE, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROJECTS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:S
Authorized Official - Last Name:GRAF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-697-6177
Mailing Address - Street 1:105 W ORCHARD AVE
Mailing Address - Street 2:
Mailing Address - City:SELAH
Mailing Address - State:WA
Mailing Address - Zip Code:98942-1329
Mailing Address - Country:US
Mailing Address - Phone:509-697-6177
Mailing Address - Fax:509-697-6659
Practice Address - Street 1:105 W ORCHARD AVE
Practice Address - Street 2:
Practice Address - City:SELAH
Practice Address - State:WA
Practice Address - Zip Code:98942-1329
Practice Address - Country:US
Practice Address - Phone:509-697-6177
Practice Address - Fax:509-697-6659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2610001320152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA17129OtherL & I
WA2051902Medicaid
WA8905978OtherL & I CRIME VICTIMS
WAC 600 340 4768OtherUBI #
G8869701Medicare PIN