Provider Demographics
NPI:1073785671
Name:WILSONVILLE VISION CENTER PC
Entity Type:Organization
Organization Name:WILSONVILLE VISION CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:J. RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRISTIANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-682-3234
Mailing Address - Street 1:29890 SW TOWN CENTER LOOP W STE E
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-9494
Mailing Address - Country:US
Mailing Address - Phone:503-682-3234
Mailing Address - Fax:503-682-0414
Practice Address - Street 1:29890 SW TOWN CENTER LOOP W
Practice Address - Street 2:STE E
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-9494
Practice Address - Country:US
Practice Address - Phone:503-682-3234
Practice Address - Fax:503-682-0414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-24
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2750152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR117936Medicare PIN