1669856902 NPI number — NORTHWEST EYE CARE 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 1669856902 NPI number — NORTHWEST EYE CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST EYE CARE 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:
6
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:
1669856902
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15259 SE 82ND DR
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
CLACKAMAS
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97015-6609
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-657-0321
Provider Business Mailing Address Fax Number:
503-657-7066

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15259 SE 82ND DR
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
CLACKAMAS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97015-6609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-657-0321
Provider Business Practice Location Address Fax Number:
503-657-7066
Provider Enumeration Date:
07/16/2015

Additional Information

Authorized Official

Authorized Official Last Name:
WOJCIECHOWSKI
Authorized Official First Name:
BRUCE
Authorized Official Middle Name:
ROBERT
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
503-657-0321

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1620ATI , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152WV0400X , with the licence number: 1620ATI , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0213843 . This is a "WORKER'S COMPENSATOIN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 282442 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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