Provider Demographics
NPI:1881236008
Name:DR. ANWI ETAME OD PROFESSIONAL OPTOMETRIC CORPORATION
Entity type:Organization
Organization Name:DR. ANWI ETAME OD PROFESSIONAL OPTOMETRIC CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:O.D./ OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:ANWI
Authorized Official - Middle Name:NGANDO
Authorized Official - Last Name:ETAME
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:503-809-9624
Mailing Address - Street 1:2012 CEDAR RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-8355
Mailing Address - Country:US
Mailing Address - Phone:503-809-9624
Mailing Address - Fax:
Practice Address - Street 1:900 S MAIN ST STE 351
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-7024
Practice Address - Country:US
Practice Address - Phone:817-527-9800
Practice Address - Fax:817-993-4033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-09
Last Update Date:2019-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center