Healthcare Provider Details

I. General information

NPI: 1174549364
Provider Name (Legal Business Name): SUNSET EYE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 04/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1865 NW 169TH PL SUITE 105
BEAVERTON OR
97006-7327
US

IV. Provider business mailing address

1865 NW 169TH PL SUITE 105
BEAVERTON OR
97006-7327
US

V. Phone/Fax

Practice location:
  • Phone: 503-533-8441
  • Fax: 503-533-8403
Mailing address:
  • Phone: 503-533-8441
  • Fax: 503-533-8403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2877ATI
License Number StateOR

VIII. Authorized Official

Name: DR. KENNY B LEE
Title or Position: PARTNER
Credential: OD
Phone: 503-533-8441