Healthcare Provider Details

I. General information

NPI: 1205078284
Provider Name (Legal Business Name): ELEMENTAL EYECARE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2009
Last Update Date: 08/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2736 NW CROSSING DR SUITE 120
BEND OR
97701
US

IV. Provider business mailing address

2736 NW CROSSING DR SUITE 120
BEND OR
97701-7180
US

V. Phone/Fax

Practice location:
  • Phone: 541-323-3937
  • Fax: 541-323-3938
Mailing address:
  • Phone: 541-323-3937
  • Fax: 541-323-3938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2635 ATI
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number2635 ATI
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number2635 ATI
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MRS. GABRIELLE WARREN MARSHALL
Title or Position: OWNER
Credential: O.D.
Phone: 541-323-3937