Individual
ELIJAH ALLAN JACKSON BANNISTER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
OD
Contact information
Practice address
820 OCEAN BEACH HWY STE 100, LONGVIEW, WA 98632-4081
(360) 636-2020
Mailing address
PO BOX 1939, KALAMA, WA 98625-1700
(360) 560-5322
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
OD61311755
WA
Other
Enumeration date
06/28/2022
Last updated
08/02/2022
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