Provider Demographics
NPI:1760894356
Name:HERITAGE EYECARE
Entity Type:Organization
Organization Name:HERITAGE EYECARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANALICIA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:CZUPRYK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:503-701-2557
Mailing Address - Street 1:2169 14TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97322-8510
Mailing Address - Country:US
Mailing Address - Phone:541-926-2061
Mailing Address - Fax:541-926-4845
Practice Address - Street 1:2169 14TH AVE SE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97322-8510
Practice Address - Country:US
Practice Address - Phone:541-926-2061
Practice Address - Fax:541-926-4845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-29
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3445ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1710248638OtherINDIVIDUAL NPI