1780972778 NPI number — TIGARD VISION WORLD, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780972778 NPI number — TIGARD VISION WORLD, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIGARD VISION WORLD, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
TIGARD VISION WORLD
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780972778
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/01/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9975 SW FREWING ST
Provider Second Line Business Mailing Address:
SUITE 130
Provider Business Mailing Address City Name:
TIGARD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97223-5091
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-906-3596
Provider Business Mailing Address Fax Number:
503-906-1014

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9975 SW FREWING ST
Provider Second Line Business Practice Location Address:
SUITE 130
Provider Business Practice Location Address City Name:
TIGARD
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97223-5091
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-906-3596
Provider Business Practice Location Address Fax Number:
503-906-1014
Provider Enumeration Date:
07/12/2011

Additional Information

Authorized Official

Authorized Official Last Name:
HARRIS
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
DONALD
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
503-703-7451

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1863T , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 500774223 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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