Provider Demographics
NPI:1497290316
Name:INTEGRATED EYECARE HOLDINGS, LLC
Entity Type:Organization
Organization Name:INTEGRATED EYECARE HOLDINGS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIRSTEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:OD, MS
Authorized Official - Phone:541-382-5701
Mailing Address - Street 1:452 NE GREENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4645
Mailing Address - Country:US
Mailing Address - Phone:541-382-5701
Mailing Address - Fax:
Practice Address - Street 1:452 NE GREENWOOD AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4645
Practice Address - Country:US
Practice Address - Phone:541-382-5701
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-01
Last Update Date:2017-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3133ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR218686Medicaid
ORR141778Medicare PIN