Provider Demographics
NPI:1811064967
Name:COFFMAN VISION CLINIC INC
Entity type:Organization
Organization Name:COFFMAN VISION CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:COFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:541-389-4774
Mailing Address - Street 1:61535 S HIGHWAY 97
Mailing Address - Street 2:STE. 16
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-2154
Mailing Address - Country:US
Mailing Address - Phone:541-389-4774
Mailing Address - Fax:541-389-3971
Practice Address - Street 1:61535 S HIGHWAY 97
Practice Address - Street 2:STE. 16
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-2154
Practice Address - Country:US
Practice Address - Phone:541-389-4774
Practice Address - Fax:541-389-3971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2508T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1982799789OtherINDIVIDUAL NPI
ORR116227OtherMEDICARE GROUP #
OR1982799789OtherINDIVIDUAL NPI
OR5105820001Medicare ID - Type Unspecified
ORU57408Medicare UPIN