Provider Demographics
NPI:1376773960
Name:LA GRANDE FAMILY EYE CARE
Entity Type:Organization
Organization Name:LA GRANDE FAMILY EYE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:HEBER
Authorized Official - Last Name:KIMBALL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:541-963-3788
Mailing Address - Street 1:1502 N PINE ST
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850
Mailing Address - Country:US
Mailing Address - Phone:541-963-3788
Mailing Address - Fax:541-963-3091
Practice Address - Street 1:1502 N PINE ST
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850
Practice Address - Country:US
Practice Address - Phone:541-963-3788
Practice Address - Fax:541-963-3091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-17
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3311AT332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500609247Medicaid
OR6353830001Medicare NSC