Provider Demographics
NPI:1730362435
Name:OPTICAL SHOP OF WA INC
Entity type:Organization
Organization Name:OPTICAL SHOP OF WA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DOLORES
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:FRAIRE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-427-7553
Mailing Address - Street 1:1635 OLYMPIC HWY N
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-3065
Mailing Address - Country:US
Mailing Address - Phone:360-427-7553
Mailing Address - Fax:360-426-2033
Practice Address - Street 1:1635 OLYMPIC HWY N
Practice Address - Street 2:SUITE 102
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-3065
Practice Address - Country:US
Practice Address - Phone:360-427-7553
Practice Address - Fax:360-426-2033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3108152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB18133Medicare PIN
WA1051190001Medicare NSC
WAU83955Medicare UPIN