Healthcare Provider Details

I. General information

NPI: 1902269525
Provider Name (Legal Business Name): GWEN THILAVANH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2016
Last Update Date: 08/22/2026
Certification Date: 08/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9201 SE 91ST AVE STE 130
HAPPY VALLEY OR
97086-3760
US

IV. Provider business mailing address

9201 SE 91ST AVE STE 130
HAPPY VALLEY OR
97086-3760
US

V. Phone/Fax

Practice location:
  • Phone: 503-775-2424
  • Fax: 503-775-6181
Mailing address:
  • Phone: 503-775-2424
  • Fax: 503-775-6181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberATI4304
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: