Provider Demographics
NPI:1952515918
Name:FAMILY VISION OF OREGON PC
Entity Type:Organization
Organization Name:FAMILY VISION OF OREGON PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:LEROY
Authorized Official - Last Name:MANNEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:503-397-2020
Mailing Address - Street 1:1864 COLUMBIA BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT HELENS
Mailing Address - State:OR
Mailing Address - Zip Code:97051-1733
Mailing Address - Country:US
Mailing Address - Phone:503-397-2020
Mailing Address - Fax:503-397-7701
Practice Address - Street 1:1864 COLUMBIA BLVD
Practice Address - Street 2:
Practice Address - City:SAINT HELENS
Practice Address - State:OR
Practice Address - Zip Code:97051-1733
Practice Address - Country:US
Practice Address - Phone:503-397-2020
Practice Address - Fax:503-397-7701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROR 1494 ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR127704Medicaid
OR127704Medicaid
OR0196560002Medicare NSC
ORR103949Medicare PIN