Healthcare Provider Details

I. General information

NPI: 1063269488
Provider Name (Legal Business Name): ALLIE DE LA CRUZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2024
Last Update Date: 07/07/2025
Certification Date: 07/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4655 SW GRIFFITH DR STE 165
BEAVERTON OR
97005-8731
US

IV. Provider business mailing address

4655 SW GRIFFITH DR STE 165
BEAVERTON OR
97005-8731
US

V. Phone/Fax

Practice location:
  • Phone: 503-646-8592
  • Fax: 503-526-3989
Mailing address:
  • Phone: 503-646-8592
  • Fax: 503-526-3989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberATI4733
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: