Provider Demographics
NPI:1598000903
Name:WILLOW CREEK EYE CARE INC.
Entity Type:Organization
Organization Name:WILLOW CREEK EYE CARE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAOLA
Authorized Official - Middle Name:F
Authorized Official - Last Name:VITIELLO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:503-645-8002
Mailing Address - Street 1:14740 NW CORNELL RD STE 110
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-5400
Mailing Address - Country:US
Mailing Address - Phone:503-645-8002
Mailing Address - Fax:
Practice Address - Street 1:14740 NW CORNELL RD STE 110
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-5400
Practice Address - Country:US
Practice Address - Phone:503-645-8002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-11
Last Update Date:2012-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2040ATI152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty