Provider Demographics
NPI:1043321508
Name:CENTRAL WASHINGTON OPTICAL, LLC
Entity type:Organization
Organization Name:CENTRAL WASHINGTON OPTICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:HATCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-248-5176
Mailing Address - Street 1:3902 CREEKSIDE LOOP
Mailing Address - Street 2:SUITE 110
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-4876
Mailing Address - Country:US
Mailing Address - Phone:509-248-5176
Mailing Address - Fax:509-248-0621
Practice Address - Street 1:3902 CREEKSIDE LOOP
Practice Address - Street 2:SUITE 110
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-4876
Practice Address - Country:US
Practice Address - Phone:509-248-5176
Practice Address - Fax:509-248-0621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADO00001728156FX1800X
WA602255023332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2026730Medicaid
WA2026730Medicaid