Provider Demographics
NPI:1629242938
Name:MEDICAL EYE CENTER OPTICAL INC
Entity Type:Organization
Organization Name:MEDICAL EYE CENTER OPTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:CASEBOLT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-779-4711
Mailing Address - Street 1:2727 E BARNETT RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8331
Mailing Address - Country:US
Mailing Address - Phone:541-779-4711
Mailing Address - Fax:541-618-1485
Practice Address - Street 1:881 NE 7TH ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1634
Practice Address - Country:US
Practice Address - Phone:541-476-6302
Practice Address - Fax:541-476-1440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-17
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR040654Medicaid
OR040654Medicaid