Healthcare Provider Details

I. General information

NPI: 1053476143
Provider Name (Legal Business Name): MT. HOOD VISION CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 01/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22640 SE STARK ST
GRESHAM OR
97030-2656
US

IV. Provider business mailing address

22640 SE STARK ST
GRESHAM OR
97030-2656
US

V. Phone/Fax

Practice location:
  • Phone: 503-667-0441
  • Fax: 503-666-6718
Mailing address:
  • Phone: 503-667-0441
  • Fax: 503-666-6718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: MARK GEORGE
Title or Position: PRESIDENT
Credential: OD
Phone: 503-667-0441