Provider Demographics
NPI:1275628869
Name:HILLSBORO EYE CLINIC, PC
Entity Type:Organization
Organization Name:HILLSBORO EYE CLINIC, PC
Other - Org Name:TANASBOURNE OPTICAL
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:L
Authorized Official - Last Name:GARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-640-3708
Mailing Address - Street 1:512 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-9208
Mailing Address - Country:US
Mailing Address - Phone:503-640-3708
Mailing Address - Fax:503-693-0441
Practice Address - Street 1:18650 NW CORNELL RD
Practice Address - Street 2:SUITE 112
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-9208
Practice Address - Country:US
Practice Address - Phone:503-645-8808
Practice Address - Fax:503-693-0441
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HILLSBORO EYE CLINIC, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-03
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR278569Medicaid
OR0306240003Medicare NSC
OR278569Medicaid