Provider Demographics
NPI:1083690655
Name:KEIZER VISION SOURCE PC
Entity Type:Organization
Organization Name:KEIZER VISION SOURCE PC
Other - Org Name:KEIZER VISION CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:S
Authorized Official - Last Name:STRAWN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:503-393-6060
Mailing Address - Street 1:4350 CHERRY AVE NE
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97303-4855
Mailing Address - Country:US
Mailing Address - Phone:503-393-6060
Mailing Address - Fax:503-393-5096
Practice Address - Street 1:4350 CHERRY AVE NE
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-4855
Practice Address - Country:US
Practice Address - Phone:503-393-6060
Practice Address - Fax:503-393-5096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-15
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR5378660001Medicare NSC
ORR132167Medicare PIN