Provider Demographics
NPI:1831304674
Name:EYEHEALTH NORTHWEST OPTI CAL, LLC
Entity Type:Organization
Organization Name:EYEHEALTH NORTHWEST OPTI CAL, LLC
Other - Org Name:NORTH PORTLAND OPTICAL
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:WELLS
Authorized Official - Last Name:BENTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-557-2020
Mailing Address - Street 1:11086 SE OAK ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-6692
Mailing Address - Country:US
Mailing Address - Phone:503-557-2020
Mailing Address - Fax:
Practice Address - Street 1:3246 N LOMBARD ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-1206
Practice Address - Country:US
Practice Address - Phone:503-285-1671
Practice Address - Fax:503-285-7859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier