Provider Demographics
NPI:1447323811
Name:DAVENPORT VISION CLINIC, INC.
Entity type:Organization
Organization Name:DAVENPORT VISION CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:509-725-2000
Mailing Address - Street 1:PO BOX 27
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:WA
Mailing Address - Zip Code:99122-0027
Mailing Address - Country:US
Mailing Address - Phone:509-725-2000
Mailing Address - Fax:509-725-4231
Practice Address - Street 1:506 8TH ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:WA
Practice Address - Zip Code:99122
Practice Address - Country:US
Practice Address - Phone:509-725-2000
Practice Address - Fax:509-725-4231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA0D00003248152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA410046744OtherRAILROAD MEDICARE
WA2025815Medicaid
WAGAB24826Medicare PIN
WA410046744OtherRAILROAD MEDICARE
WA2025815Medicaid