Provider Demographics
NPI:1295210011
Name:COASTAL EYECARE TILLAMOOK LLC
Entity Type:Organization
Organization Name:COASTAL EYECARE TILLAMOOK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:L
Authorized Official - Last Name:THORSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-642-3214
Mailing Address - Street 1:819 S HOLLADAY DR
Mailing Address - Street 2:
Mailing Address - City:SEASIDE
Mailing Address - State:OR
Mailing Address - Zip Code:97138-6608
Mailing Address - Country:US
Mailing Address - Phone:503-738-5361
Mailing Address - Fax:
Practice Address - Street 1:102 MAIN AVE
Practice Address - Street 2:
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-2218
Practice Address - Country:US
Practice Address - Phone:503-374-0399
Practice Address - Fax:503-374-0374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-27
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery