1194940726 NPI number — EYEHEALTH NORTHWEST OPTICAL, LLC

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 1194940726 NPI number — EYEHEALTH NORTHWEST OPTICAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYEHEALTH NORTHWEST OPTICAL, LLC
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:
Provider Other Organization Name Type Code:
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:
1194940726
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 22009
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKIE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97269-2009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-344-5102
Provider Business Mailing Address Fax Number:
503-344-5110

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11086 SE OAK ST
Provider Second Line Business Practice Location Address:
ADMINISTRATION
Provider Business Practice Location Address City Name:
MILWAUKIE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97222-6692
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-344-5102
Provider Business Practice Location Address Fax Number:
503-344-5110
Provider Enumeration Date:
04/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BENTLEY
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
WELLS
Authorized Official Title or Position:
OFFICER
Authorized Official Telephone Number:
503-557-2020

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1243050004 . This is a "DURABLE MEDICAL EQUIPMENT" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 1243050002 . This is a "DURABLE MEDICAL EQUIPMENT" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 1243050003 . This is a "DURABLE MEDICAL EQUIPMENT" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 1243050006 . This is a "DURABLE MEDICAL EQUIPMENT" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 1243050005 . This is a "DURABLE MEDICAL EQUIPMENT" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 1243050001 . This is a "DURABLE MEDICAL EQUIPMENT" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 1243050007 . This is a "DURABLE MEDICAL EQUIPMENT" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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