MEDICARE: PDX EYE AND VISION CARE 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	152W00000X	Optometrist	3568ATI	OR

General Provider Information

NPI Number	:	1326594987
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PDX EYE AND VISION CARE LLC

Provider Business Mailing Address
First Line	:	2480 NE FREMONT ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97212-2509
Country	:	US
Telephone Number	:	503-284-3937
Fax Number	:	503-281-5711

Provider Business Practice Location Address
First Line	:	2480 NE FREMONT ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97212-2509
Country	:	US
Telephone Number	:	503-284-3937
Fax Number	:	503-281-5711

Authorized Official
Title or Position	:	OWNER
Name	:	CHRISTOPHER PALMER
Credential	:	O.D.
Telephone Number	:	503-284-3937

Provider Enumeration Date	:	09/01/2016
Last Update Date	:	09/01/2016

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