1962641654 NPI number — MT SCOTT VISION AND OCULAR IMAGING CENTER PC

Table of content: (NPI 1962641654)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962641654 NPI number — MT SCOTT VISION AND OCULAR IMAGING CENTER PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MT SCOTT VISION AND OCULAR IMAGING CENTER PC
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:
1962641654
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/13/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11002 NE 102ND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98662-1584
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-652-1479
Provider Business Mailing Address Fax Number:
503-652-1690

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9300 NE 91ST AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
HAPPY VALLEY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97086
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-652-1479
Provider Business Practice Location Address Fax Number:
503-652-1690
Provider Enumeration Date:
02/19/2009

Additional Information

Authorized Official

Authorized Official Last Name:
FORBES
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
503-250-0040

Provider Taxonomy Codes

  • Taxonomy code: 152WC0802X , with the licence number:  3003AIT , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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