Provider Demographics
NPI:1780933945
Name:SHELTON FAMILY EYE CARE, LLC
Entity type:Organization
Organization Name:SHELTON FAMILY EYE CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-601-7796
Mailing Address - Street 1:100 E WALLACE KNEELAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-2981
Mailing Address - Country:US
Mailing Address - Phone:360-427-8325
Mailing Address - Fax:360-427-8326
Practice Address - Street 1:100 E WALLACE KNEELAND BLVD
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-2981
Practice Address - Country:US
Practice Address - Phone:360-427-8325
Practice Address - Fax:360-427-8326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-04
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD 60292781152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1679838874OtherPERSONAL NPI