Provider Demographics
NPI:1639822521
Name:ESTACADA EYECARE PC
Entity Type:Organization
Organization Name:ESTACADA EYECARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMRITA
Authorized Official - Middle Name:
Authorized Official - Last Name:KANG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:503-462-3811
Mailing Address - Street 1:PO BOX 358
Mailing Address - Street 2:
Mailing Address - City:ESTACADA
Mailing Address - State:OR
Mailing Address - Zip Code:97023-0358
Mailing Address - Country:US
Mailing Address - Phone:503-630-3528
Mailing Address - Fax:
Practice Address - Street 1:405 NE MAIN ST
Practice Address - Street 2:
Practice Address - City:ESTACADA
Practice Address - State:OR
Practice Address - Zip Code:97023-8528
Practice Address - Country:US
Practice Address - Phone:503-630-3528
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-31
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1508210139Medicaid