Basic Information
| Provider Information | |||||||||
| NPI: | 1902888118 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EAST PORTLAND OPTICAL SERVICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22009 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKIE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972692009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035572020 | ||||||||
| FaxNumber: | 5033445110 | ||||||||
| Practice Location | |||||||||
| Address1: | 10819 SE STARK ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972163161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032552291 | ||||||||
| FaxNumber: | 5032521797 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2005 | ||||||||
| LastUpdateDate: | 09/17/2008 | ||||||||
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| AuthorizedOfficialLastName: | PLUMB | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | FREDERICK | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER/MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5035572020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
No ID Information.