Basic Information
| Provider Information | |||||||||
| NPI: | 1497415426 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EYE HEALTH NORTHWEST P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22009 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972692009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035587372 | ||||||||
| FaxNumber: | 5033445140 | ||||||||
| Practice Location | |||||||||
| Address1: | 2318 E PORTLAND RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | NEWBERG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971321374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035381833 | ||||||||
| FaxNumber: | 5035386081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2021 | ||||||||
| LastUpdateDate: | 12/17/2021 | ||||||||
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| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | BRETT | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5035381833 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EYE HEALTH NORTHWEST P.C. | ||||||||
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| NPICertificationDate: | 12/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.