Healthcare Provider Details

I. General information

NPI: 1982181186
Provider Name (Legal Business Name): ROGUE FAMILY EYE CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2018
Last Update Date: 02/24/2022
Certification Date: 02/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

853 NE A ST
GRANTS PASS OR
97526
US

IV. Provider business mailing address

853 NE A ST
GRANTS PASS OR
97526-2211
US

V. Phone/Fax

Practice location:
  • Phone: 541-218-9966
  • Fax:
Mailing address:
  • Phone: 541-218-9966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number2980ATI
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number2980ATI
License Number StateOR
# 4
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2980ATI
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier2980ATI
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerOREGON BOARD OF OPTOMETRY

VIII. Authorized Official

Name: DR. MATTHEW SCOT RICHARDSON
Title or Position: PRESIDENT, OPTOMETRIC PHYSICIAN
Credential: OD
Phone: 541-474-2788