Provider Demographics
NPI:1801973110
Name:HIGH DESERT EYECARE
Entity type:Organization
Organization Name:HIGH DESERT EYECARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ALISHIA
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:
Authorized Official - Credentials:CPOA, CPOC, VSR
Authorized Official - Phone:541-923-2221
Mailing Address - Street 1:PO BOX 918
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-0206
Mailing Address - Country:US
Mailing Address - Phone:541-923-2221
Mailing Address - Fax:541-923-3776
Practice Address - Street 1:443 SW EVERGREEN AVE
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-2817
Practice Address - Country:US
Practice Address - Phone:541-923-2221
Practice Address - Fax:541-923-3776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332H00000X
OR2601AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR297153Medicaid
OR244121Medicaid
OR236083Medicaid
OR213242Medicaid
OR5112620001Medicare NSC
OR244121Medicaid
OR236083Medicaid
OR213242Medicaid
ORR118034Medicare PIN
ORR140083Medicare PIN
ORR118032Medicare PIN