Provider Demographics
NPI:1861697070
Name:MEDICAL VISION CENTER, LTD
Entity type:Organization
Organization Name:MEDICAL VISION CENTER, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:A
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-496-5140
Mailing Address - Street 1:240 W. MAIN ST.
Mailing Address - Street 2:P.O. BOX AC
Mailing Address - City:MORTON
Mailing Address - State:WA
Mailing Address - Zip Code:98356
Mailing Address - Country:US
Mailing Address - Phone:360-496-5140
Mailing Address - Fax:360-496-6039
Practice Address - Street 1:240 W. MAIN ST.
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:WA
Practice Address - Zip Code:98356
Practice Address - Country:US
Practice Address - Phone:360-496-5140
Practice Address - Fax:360-496-6039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00000957152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2018240Medicaid
WA2018240Medicaid
WAGABO2694Medicare ID - Type Unspecified