Provider Demographics
NPI:1710719034
Name:VALLEY VISION SOURCE PS
Entity type:Organization
Organization Name:VALLEY VISION SOURCE PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLENBECK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:425-545-1010
Mailing Address - Street 1:22410 SE 282ND CT
Mailing Address - Street 2:
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-5171
Mailing Address - Country:US
Mailing Address - Phone:425-891-9875
Mailing Address - Fax:
Practice Address - Street 1:17800 TALBOT RD S STE 200
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5740
Practice Address - Country:US
Practice Address - Phone:425-545-1010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-15
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty