Provider Demographics
NPI:1083625735
Name:COLUMBIAN EYECARE, LLC
Entity Type:Organization
Organization Name:COLUMBIAN EYECARE, LLC
Other - Org Name:COLUMBIAN EYECARE,LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:W
Authorized Official - Last Name:RIPPER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:541-772-9990
Mailing Address - Street 1:1175 ROYAL AVENUE SUITE A
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6122
Mailing Address - Country:US
Mailing Address - Phone:541-772-9990
Mailing Address - Fax:541-772-5003
Practice Address - Street 1:1175 ROYAL AVENUE SUITE A
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6122
Practice Address - Country:US
Practice Address - Phone:541-772-9990
Practice Address - Fax:541-772-5003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1247ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR276214Medicaid
OR276214Medicaid
OR5925850001Medicare NSC
ORU29866Medicare UPIN