Provider Demographics
NPI:1578899472
Name:RIVER CITY EYECARE, LLC
Entity Type:Organization
Organization Name:RIVER CITY EYECARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BREEDEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:503-775-2424
Mailing Address - Street 1:9201 SE 91ST AVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97086-3760
Mailing Address - Country:US
Mailing Address - Phone:503-775-2424
Mailing Address - Fax:503-775-6181
Practice Address - Street 1:9201 SE 91ST AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97086-3760
Practice Address - Country:US
Practice Address - Phone:503-775-2424
Practice Address - Fax:503-775-6181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-27
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR149908Medicare PIN