NPIMap

Organization Active NPI

Kitsap Eyecare Centers Inc PS

  • Optometrist
  • Poulsbo, WA
National Provider Identifier
1477612463
Registry record updated Jun 11, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
OptometristTaxonomy code 152W00000X
License
601379904 Issued in WA
Legal business name
KITSAP EYECARE CENTERS INC PS
Practice address
19220 8TH Ave NE
Suite a
Poulsbo, WA 98370-8773
Phone
(360) 779-2336
Fax
(360) 779-7628
NPI assigned
Dec 6, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 11, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Ray G. Hedahl, O.D.NPI 1053420851
Title
President
Phone
(360) 779-2336

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
OptometristGroup: 193400000X SINGLE SPECIALTY GROUP 152W00000X 601379904 WA Primary

Addresses

Primary practice location

19220 8TH Ave NE
Suite a
Poulsbo, WA 98370-8773

Mailing address

19220 8TH Ave NE Ste a
Poulsbo, WA 98370-8773
Phone (360) 779-2336

Other names 1

  • Poulsbo Eyecare Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040305001045 WA Part B Supplier - Clinic/Group Practice 2264320894 Receives reassigned benefits from 3 practitioners
Practice locations: Poulsbo, WA

National Provider Directory

National Provider Directory

Locations

19220 8th Ave NE
#A
Poulsbo, WA 98370
Phone (360) 779-2336

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1165363200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1623369600000",
    "number": "1477612463",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "19220 8TH AVE NE STE A",
            "city": "POULSBO",
            "state": "WA",
            "postal_code": "983708773",
            "telephone_number": "360-779-2336",
            "fax_number": "360-779-7628"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "19220 8TH AVE NE",
            "address_2": "SUITE A",
            "city": "POULSBO",
            "state": "WA",
            "postal_code": "983708773",
            "telephone_number": "360-779-2336",
            "fax_number": "360-779-7628"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KITSAP EYECARE CENTERS INC PS",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-12-06",
        "last_updated": "2021-06-11",
        "certification_date": "2021-06-11",
        "status": "A",
        "authorized_official_last_name": "HEDAHL",
        "authorized_official_first_name": "RAY",
        "authorized_official_middle_name": "G.",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "360-779-2336",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "O.D."
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Optometrist",
            "state": "WA",
            "license": "601379904",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Poulsbo Eyecare Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Poulsbo Eyecare Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Poulsbo, WA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 11, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.