Provider Demographics
NPI:1689782393
Name:PACIFIC UNIVERSITY
Entity Type:Organization
Organization Name:PACIFIC UNIVERSITY
Other - Org Name:PACIFIC UNIVERSITY EYECLINIC FOREST GROVE
Other - Org Type:Other Name
Authorized Official - Title/Position:COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:DOWNING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-352-2663
Mailing Address - Street 1:2043 COLLEGE WAY
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-1797
Mailing Address - Country:US
Mailing Address - Phone:503-352-2020
Mailing Address - Fax:971-266-2958
Practice Address - Street 1:2043 COLLEGE WAY
Practice Address - Street 2:
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-1797
Practice Address - Country:US
Practice Address - Phone:503-352-2020
Practice Address - Fax:503-352-2261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X, 261QM1300X
OR163863156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR154054Medicaid
OR154054Medicaid