Provider Demographics
NPI:1497931018
Name:MOLALLA VISION CLINIC PC
Entity Type:Organization
Organization Name:MOLALLA VISION CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:WALLACE
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:503-829-9186
Mailing Address - Street 1:PO BOX 480
Mailing Address - Street 2:
Mailing Address - City:MOLALLA
Mailing Address - State:OR
Mailing Address - Zip Code:97038-0480
Mailing Address - Country:US
Mailing Address - Phone:503-829-9186
Mailing Address - Fax:503-829-8402
Practice Address - Street 1:502 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MOLALLA
Practice Address - State:OR
Practice Address - Zip Code:97038-9148
Practice Address - Country:US
Practice Address - Phone:503-829-9186
Practice Address - Fax:503-829-8402
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:J. WALLACE WALKER OD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-14
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2487ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR260661Medicaid
OR0650800001Medicare NSC
ORR0000PHDBLMedicare PIN