Healthcare Provider Details

I. General information

NPI: 1689914400
Provider Name (Legal Business Name): SUSTAINABLE VISION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2013
Last Update Date: 02/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11800 SE 82ND AVE
HAPPY VALLEY OR
97086-7711
US

IV. Provider business mailing address

PO BOX 86221
PORTLAND OR
97286-0221
US

V. Phone/Fax

Practice location:
  • Phone: 503-660-3093
  • Fax: 503-654-5429
Mailing address:
  • Phone: 971-263-0495
  • Fax: 503-654-5429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3462ATI
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number3462ATI
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number3462ATI
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number3462ATI
License Number StateOR
# 5
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number3462ATI
License Number StateOR
# 6
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number3462ATI
License Number StateOR
# 7
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License Number3462ATI
License Number StateOR

VIII. Authorized Official

Name: DR. SAMUEL EDWARD ADELMAN
Title or Position: MEMBER
Credential: O.D.
Phone: 971-263-0495