Provider Demographics
NPI:1760669733
Name:POLK VISION CLINICS INC.
Entity Type:Organization
Organization Name:POLK VISION CLINICS INC.
Other - Org Name:DALLAS VISION CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:W
Authorized Official - Last Name:KNOWLES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:503-623-9233
Mailing Address - Street 1:506 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338-1915
Mailing Address - Country:US
Mailing Address - Phone:503-623-9233
Mailing Address - Fax:503-623-9233
Practice Address - Street 1:506 MAIN ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-1915
Practice Address - Country:US
Practice Address - Phone:503-623-9233
Practice Address - Fax:503-623-9233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1547T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR024687Medicaid
ORR141189Medicare PIN
OR024687Medicaid
ORDN3412Medicare PIN