Provider Demographics
NPI:1750331880
Name:CANBY EYECARE INC
Entity Type:Organization
Organization Name:CANBY EYECARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:D
Authorized Official - Last Name:CHASE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:506-266-4847
Mailing Address - Street 1:364 N IVY ST
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:OR
Mailing Address - Zip Code:97013-3704
Mailing Address - Country:US
Mailing Address - Phone:503-266-4847
Mailing Address - Fax:503-266-1106
Practice Address - Street 1:364 N IVY ST
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-3704
Practice Address - Country:US
Practice Address - Phone:503-266-4847
Practice Address - Fax:503-266-1106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1200ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR134792Medicare PIN
OR0000PGBZTMedicare ID - Type Unspecified
OR1026320001Medicare NSC
ORT67501Medicare UPIN