Provider Demographics
NPI:1124225842
Name:PACIFIC UNIVERSITY
Entity Type:Organization
Organization Name:PACIFIC UNIVERSITY
Other - Org Name:PACIFIC UNIVERSITY EYECLINIC CORNELIUS
Other - Org Type:Other Name
Authorized Official - Title/Position:COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:DOWNING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-352-2663
Mailing Address - Street 1:2043 COLLEGE WAY
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-1756
Mailing Address - Country:US
Mailing Address - Phone:503-352-8543
Mailing Address - Fax:971-266-2960
Practice Address - Street 1:1151 N ADAIR ST STE 104
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:OR
Practice Address - Zip Code:97113-8900
Practice Address - Country:US
Practice Address - Phone:503-352-8543
Practice Address - Fax:971-266-2960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR274669Medicaid