Provider Demographics
NPI:1205078284
Name:ELEMENTAL EYECARE, PC
Entity type:Organization
Organization Name:ELEMENTAL EYECARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GABRIELLE
Authorized Official - Middle Name:WARREN
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:541-323-3937
Mailing Address - Street 1:2736 NW CROSSING DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-7180
Mailing Address - Country:US
Mailing Address - Phone:541-323-3937
Mailing Address - Fax:541-323-3938
Practice Address - Street 1:2736 NW CROSSING DR
Practice Address - Street 2:SUITE 120
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701
Practice Address - Country:US
Practice Address - Phone:541-323-3937
Practice Address - Fax:541-323-3938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-06
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332H00000X
OR2635 ATI152WP0200X, 152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty