Provider Demographics
NPI:1366633679
Name:WALDPORT EYE CARE LLC
Entity Type:Organization
Organization Name:WALDPORT EYE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:541-563-4100
Mailing Address - Street 1:PO BOX 888
Mailing Address - Street 2:
Mailing Address - City:WALDPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97394-0888
Mailing Address - Country:US
Mailing Address - Phone:541-563-4100
Mailing Address - Fax:541-563-4468
Practice Address - Street 1:525 NW WILLOW
Practice Address - Street 2:
Practice Address - City:WALDPORT
Practice Address - State:OR
Practice Address - Zip Code:97394
Practice Address - Country:US
Practice Address - Phone:541-563-4100
Practice Address - Fax:541-563-4468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR299057Medicaid
ORR139379Medicare PIN
OR299057Medicaid