Healthcare Provider Details

I. General information

NPI: 1063982239
Provider Name (Legal Business Name): OREGON PHYSICIANS EYECARE GROUP, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2018
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 NW BURNSIDE RD
GRESHAM OR
97030-3851
US

IV. Provider business mailing address

1615 S CONGRESS AVE STE 105
DELRAY BEACH FL
33445-6326
US

V. Phone/Fax

Practice location:
  • Phone: 971-220-5605
  • Fax: 503-912-5202
Mailing address:
  • Phone: 561-275-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ALISHA JACKSON
Title or Position: SENIOR REVENUE CYCLE MANAGER
Credential:
Phone: 561-208-1591