Healthcare Provider Details

I. General information

NPI: 1386292852
Provider Name (Legal Business Name): PACIFIC UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2019
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2043 COLLEGE WAY
FOREST GROVE OR
97116-1797
US

IV. Provider business mailing address

2043 COLLEGE WAY
FOREST GROVE OR
97116-1797
US

V. Phone/Fax

Practice location:
  • Phone: 503-352-2020
  • Fax: 503-352-2046
Mailing address:
  • Phone: 503-352-2020
  • Fax: 503-352-2046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: LISA DOWNING
Title or Position: COMPLIANCE OFFICER
Credential:
Phone: 503-352-2663