Provider Demographics
NPI:1770564445
Name:PROFESSIONAL VISION SERVICES, PS
Entity type:Organization
Organization Name:PROFESSIONAL VISION SERVICES, PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:L
Authorized Official - Last Name:BIRCUMSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:253-473-3443
Mailing Address - Street 1:4620 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98408-7738
Mailing Address - Country:US
Mailing Address - Phone:253-473-3443
Mailing Address - Fax:253-473-7127
Practice Address - Street 1:4620 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98408-7738
Practice Address - Country:US
Practice Address - Phone:253-473-3443
Practice Address - Fax:253-473-7127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1349152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA209-783OtherOFFICE OF DISABILITY INSURANCE
WA1203680OtherDSHS VENDOR
WA0179OtherNBN
WA482,107-02OtherL & I WORKERS COMP
WA61722OtherSPECTERA
BI 0008OtherREGENCE BLUE SHIELD
WAG8878811OtherMEDICARE PTAN
WAW912748OtherCHAMPUS
WA0179OtherNBN
WA61722OtherSPECTERA
WAGAB 04232Medicare ID - Type UnspecifiedMIDICARE NUMBER