Provider Demographics
NPI:1235325176
Name:LIGHTHOUSE VISION CARE, P.C.
Entity Type:Organization
Organization Name:LIGHTHOUSE VISION CARE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:K
Authorized Official - Last Name:DEHAAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:503-842-6363
Mailing Address - Street 1:310 STILLWELL AVE
Mailing Address - Street 2:
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-2119
Mailing Address - Country:US
Mailing Address - Phone:503-842-6363
Mailing Address - Fax:503-842-6204
Practice Address - Street 1:310 STILLWELL AVE
Practice Address - Street 2:
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-2119
Practice Address - Country:US
Practice Address - Phone:503-842-6363
Practice Address - Fax:503-842-6204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2858T152W00000X, 152WC0802X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR182762Medicaid
ORX71059Medicare UPIN
OR182762Medicaid