Provider Demographics
NPI:1164791414
Name:MADRAS VISION SOURCE PC
Entity Type:Organization
Organization Name:MADRAS VISION SOURCE PC
Other - Org Name:MADRAS VISION SOURCE LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:BROOKE
Authorized Official - Last Name:TEGAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:541-475-2020
Mailing Address - Street 1:211 SE 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MADRAS
Mailing Address - State:OR
Mailing Address - Zip Code:97741
Mailing Address - Country:US
Mailing Address - Phone:541-475-2020
Mailing Address - Fax:541-475-6118
Practice Address - Street 1:211 SE 5TH ST
Practice Address - Street 2:
Practice Address - City:MADRAS
Practice Address - State:OR
Practice Address - Zip Code:97741
Practice Address - Country:US
Practice Address - Phone:541-475-2020
Practice Address - Fax:541-475-6118
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MADRAS VISION SOURCE PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-15
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3215ATI152W00000X
332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty