Healthcare Provider Details

I. General information

NPI: 1174714943
Provider Name (Legal Business Name): EYEHEALTH NORTHWEST OPTICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2007
Last Update Date: 08/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6111 NE CORNELL RD
HILLSBORO OR
97124-5410
US

IV. Provider business mailing address

11086 SE OAK ST
MILWAUKIE OR
97222-6692
US

V. Phone/Fax

Practice location:
  • Phone: 503-846-9400
  • Fax: 503-846-9500
Mailing address:
  • Phone: 503-557-2020
  • Fax: 503-344-5110

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. ROBERT WELLS BENTLEY
Title or Position: PRESIDENT
Credential: MD
Phone: 503-227-2020