Provider Demographics
NPI:1669856902
Name:NORTHWEST EYE CARE LLC
Entity Type:Organization
Organization Name:NORTHWEST EYE CARE LLC
Other - Org Name:NORTHWEST EYE CARE PROFESSIONALS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:WOJCIECHOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:503-657-0321
Mailing Address - Street 1:15259 SE 82ND DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-6609
Mailing Address - Country:US
Mailing Address - Phone:503-657-0321
Mailing Address - Fax:503-657-7066
Practice Address - Street 1:15259 SE 82ND DR
Practice Address - Street 2:SUITE 101
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-6609
Practice Address - Country:US
Practice Address - Phone:503-657-0321
Practice Address - Fax:503-657-7066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-16
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1620ATI152W00000X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0213843OtherWORKER'S COMPENSATOIN
OR282442Medicaid
OR282442Medicaid
WA0213843OtherWORKER'S COMPENSATOIN