Provider Demographics
NPI:1902953581
Name:BONNEY LAKE OPTICAL, INC
Entity Type:Organization
Organization Name:BONNEY LAKE OPTICAL, INC
Other - Org Name:SPANAWAY LAKE OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CUDAHY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-750-8135
Mailing Address - Street 1:9801 204TH AVE E
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-6559
Mailing Address - Country:US
Mailing Address - Phone:253-750-8135
Mailing Address - Fax:
Practice Address - Street 1:9801 204TH AVE E
Practice Address - Street 2:
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-6559
Practice Address - Country:US
Practice Address - Phone:253-750-8135
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X
WA1640332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2001360Medicaid
WA2001360Medicaid