Healthcare Provider Details

I. General information

NPI: 1528216793
Provider Name (Legal Business Name): CARRIE LYNN BREEDEN O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2008
Last Update Date: 08/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9201 SE 91ST AVE SUITE 130
CLACKAMAS OR
97086-3760
US

IV. Provider business mailing address

9201 SE 91ST AVE SUITE 130
CLACKAMAS OR
97086-3760
US

V. Phone/Fax

Practice location:
  • Phone: 503-775-2424
  • Fax: 503-775-6181
Mailing address:
  • Phone: 503-775-2424
  • Fax: 503-775-6181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3261ATI
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: