Provider Demographics
NPI:1164622288
Name:NORTHWEST OPTOMETRIC ASSOICATES INC
Entity Type:Organization
Organization Name:NORTHWEST OPTOMETRIC ASSOICATES INC
Other - Org Name:ABC VISIONSOURCE SHERWOOD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARI
Authorized Official - Middle Name:
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:503-625-5599
Mailing Address - Street 1:21887 SW SHERWOOD BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-9412
Mailing Address - Country:US
Mailing Address - Phone:503-625-5599
Mailing Address - Fax:
Practice Address - Street 1:21887 SW SHERWOOD BLVD STE B
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-9412
Practice Address - Country:US
Practice Address - Phone:503-625-5599
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3023ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORU55167Medicare UPIN