Provider Demographics
NPI:1275265795
Name:COOS EYE CENTERS, INC.
Entity Type:Organization
Organization Name:COOS EYE CENTERS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:541-396-4042
Mailing Address - Street 1:PO BOX 1108
Mailing Address - Street 2:
Mailing Address - City:GOLD BEACH
Mailing Address - State:OR
Mailing Address - Zip Code:97444-1108
Mailing Address - Country:US
Mailing Address - Phone:541-247-7212
Mailing Address - Fax:541-247-0490
Practice Address - Street 1:94225 4TH ST
Practice Address - Street 2:
Practice Address - City:GOLD BEACH
Practice Address - State:OR
Practice Address - Zip Code:97444-7756
Practice Address - Country:US
Practice Address - Phone:541-247-7212
Practice Address - Fax:541-247-0490
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COOS EYE CENTERS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-06-24
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR130276Medicaid