Healthcare Provider Details

I. General information

NPI: 1669856902
Provider Name (Legal Business Name): NORTHWEST EYE CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2015
Last Update Date: 07/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15259 SE 82ND DR SUITE 101
CLACKAMAS OR
97015-6609
US

IV. Provider business mailing address

15259 SE 82ND DR SUITE 101
CLACKAMAS OR
97015-6609
US

V. Phone/Fax

Practice location:
  • Phone: 503-657-0321
  • Fax: 503-657-7066
Mailing address:
  • Phone: 503-657-0321
  • Fax: 503-657-7066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number1620ATI
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1620ATI
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier0213843
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerWORKER'S COMPENSATOIN
# 2
Identifier282442
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: DR. BRUCE ROBERT WOJCIECHOWSKI
Title or Position: MANAGER
Credential: O.D.
Phone: 503-657-0321