Basic Information
| Provider Information | |||||||||
| NPI: | 1396366878 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHEDI | ||||||||
| FirstName: | SHALINI | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11086 SE OAK ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKIE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972226692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035587372 | ||||||||
| FaxNumber: | 5036070001 | ||||||||
| Practice Location | |||||||||
| Address1: | 12050 SE STEVENS RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | HAPPY VALLEY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970867667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037833300 | ||||||||
| FaxNumber: | 5037833319 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2020 | ||||||||
| LastUpdateDate: | 03/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4509 | OR | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 500793824 | 05 | OR | MEDICAID |