Provider Demographics
NPI:1720416944
Name:ADVANTAGE OPTICAL, INC.
Entity Type:Organization
Organization Name:ADVANTAGE OPTICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:LADOUCEUR
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:503-650-1839
Mailing Address - Street 1:502 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-1811
Mailing Address - Country:US
Mailing Address - Phone:503-650-1839
Mailing Address - Fax:503-650-5357
Practice Address - Street 1:502 MAIN ST
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1811
Practice Address - Country:US
Practice Address - Phone:503-650-1839
Practice Address - Fax:503-650-5357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-25
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3267ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500671079Medicaid
OR500671079Medicaid