Healthcare Provider Details

I. General information

NPI: 1285824417
Provider Name (Legal Business Name): ABC OPTOMETRIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 11/05/2020
Certification Date: 11/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2991 SE 75TH AVE
HILLSBORO OR
97123-6210
US

IV. Provider business mailing address

2991 SE 75TH AVE
HILLSBORO OR
97123-6210
US

V. Phone/Fax

Practice location:
  • Phone: 503-649-7566
  • Fax: 503-649-0123
Mailing address:
  • Phone: 503-649-7566
  • Fax: 503-649-0123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2784ATI
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL HESTER
Title or Position: SEC./TREAS.
Credential:
Phone: 503-473-8039