Healthcare Provider Details

I. General information

NPI: 1639822521
Provider Name (Legal Business Name): ESTACADA EYECARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2022
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 NE MAIN ST
ESTACADA OR
97023-8528
US

IV. Provider business mailing address

PO BOX 358
ESTACADA OR
97023-0358
US

V. Phone/Fax

Practice location:
  • Phone: 503-630-3528
  • Fax:
Mailing address:
  • Phone: 503-630-3528
  • Fax:

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: AMRITA KANG
Title or Position: PRESIDENT
Credential: OD
Phone: 503-462-3811