Basic Information
Provider Information | |||||||||
NPI: | 1578544342 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ECHO VISION INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 821350 | ||||||||
Address2: |   | ||||||||
City: | VANCOUVER | ||||||||
State: | WA | ||||||||
PostalCode: | 98682 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5032835220 | ||||||||
FaxNumber: | 5032839527 | ||||||||
Practice Location | |||||||||
Address1: | 2801 N GANTENBEIN AVE | ||||||||
Address2: | EMANUEL HOSPITAL | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 97227 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5034021660 | ||||||||
FaxNumber: | 5034021681 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/09/2005 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SCHORK | ||||||||
AuthorizedOfficialFirstName: | PETER | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 5034021660 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | RCVT RDCS AE PE | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 293D00000X |   |   | Y |   | Laboratories | Physiological Laboratory |   |
ID Information
ID | Type | State | Issuer | Description | 029071 | 05 | OR |   | MEDICAID | 7119266 | 05 | WA |   | MEDICAID |