Healthcare Provider Details

I. General information

NPI: 1184615981
Provider Name (Legal Business Name): AMANDA MARIE BALSALOBRE OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA MARIE GALSTER

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 09/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

762 E 13TH AVE
EUGENE OR
97401-3778
US

IV. Provider business mailing address

19711 DARTMOUTH AVE
BEND OR
97702-3007
US

V. Phone/Fax

Practice location:
  • Phone: 541-343-3333
  • Fax: 541-484-5578
Mailing address:
  • Phone: 541-556-8445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number3119T
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: