Provider Demographics
NPI:1912010596
Name:EYE CENTER OF BROOKINGS, LLC
Entity Type:Organization
Organization Name:EYE CENTER OF BROOKINGS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:541-469-6923
Mailing Address - Street 1:PO BOX 4005
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415-0228
Mailing Address - Country:US
Mailing Address - Phone:541-469-6923
Mailing Address - Fax:541-469-6769
Practice Address - Street 1:937 CHETCO AVE
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415
Practice Address - Country:US
Practice Address - Phone:541-469-6923
Practice Address - Fax:541-469-6769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROR 2740 ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR208317Medicaid
OR107265Medicare PIN
ORU80691Medicare UPIN
OR4508330001Medicare NSC