MEDICARE: EYE HEALTH NORTHWEST OPTICAL, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332H00000X	Eyewear Supplier

General Provider Information

NPI Number	:	1043292220
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYE HEALTH NORTHWEST OPTICAL, LLC

Provider Business Mailing Address
First Line	:	PO BOX 22009
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97269-2009
Country	:	US
Telephone Number	:	503-557-2020
Fax Number	:	503-344-5110

Provider Business Practice Location Address
First Line	:	24601 SE STARK ST
Second Line	:
City	:	TROUTDALE
State	:	OR
Zip	:	97060-3355
Country	:	US
Telephone Number	:	503-667-2431
Fax Number	:	503-252-1797

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ROBERT WELLS BENTLEY
Credential	:	MD
Telephone Number	:	503-557-2020

Provider Enumeration Date	:	11/15/2005
Last Update Date	:	09/17/2008

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