Provider Demographics
NPI:1063494243
Name:EYE HEALTH NORTHWEST OPTICAL, LLC
Entity Type:Organization
Organization Name:EYE HEALTH NORTHWEST OPTICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:WELLS
Authorized Official - Last Name:BENTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-557-2020
Mailing Address - Street 1:PO BOX 22009
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97269-2009
Mailing Address - Country:US
Mailing Address - Phone:503-557-2020
Mailing Address - Fax:503-344-5110
Practice Address - Street 1:1955 NW NORTHRUP ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-1614
Practice Address - Country:US
Practice Address - Phone:503-227-2020
Practice Address - Fax:503-222-0614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-15
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
1243050003Medicare NSC