Healthcare Provider Details

I. General information

NPI: 1619759453
Provider Name (Legal Business Name): BEND FAMILY VISION CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2023
Last Update Date: 04/16/2024
Certification Date: 04/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1470 SW KNOLL AVE STE 102
BEND OR
97702-3154
US

IV. Provider business mailing address

1470 SW KNOLL AVE STE 102
BEND OR
97702-3154
US

V. Phone/Fax

Practice location:
  • Phone: 541-797-0295
  • Fax: 541-797-7685
Mailing address:
  • Phone: 541-797-0295
  • Fax: 541-797-7685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: DIANA LEE COOPER
Title or Position: BILLING MANAGER
Credential:
Phone: 541-740-8021