Provider Demographics
NPI:1902077373
Name:STANWOOD EYE CLINIC, INC
Entity Type:Organization
Organization Name:STANWOOD EYE CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:NIXON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-629-9535
Mailing Address - Street 1:PO BOX 664
Mailing Address - Street 2:
Mailing Address - City:STANWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98292-0664
Mailing Address - Country:US
Mailing Address - Phone:360-629-9535
Mailing Address - Fax:360-629-9536
Practice Address - Street 1:27101 PIONEER HWY
Practice Address - Street 2:
Practice Address - City:STANWOOD
Practice Address - State:WA
Practice Address - Zip Code:98292
Practice Address - Country:US
Practice Address - Phone:360-629-9535
Practice Address - Fax:360-629-9536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1505TX332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2022689Medicaid
WAT03041Medicare UPIN
WA0836000001Medicare NSC