Healthcare Provider Details

I. General information

NPI: 1760636005
Provider Name (Legal Business Name): GRESHAM OPTICAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2008
Last Update Date: 08/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 NE DIVISION ST SUITE 101
GRESHAM OR
97030-5813
US

IV. Provider business mailing address

2150 NE DIVISION ST SUITE 101
GRESHAM OR
97030-5813
US

V. Phone/Fax

Practice location:
  • Phone: 503-667-2424
  • Fax: 503-492-3236
Mailing address:
  • Phone: 503-667-2424
  • Fax: 503-492-3236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: DR. GREG E BROPHY
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 503-667-2424