Healthcare Provider Details

I. General information

NPI: 1750639951
Provider Name (Legal Business Name): JOHN DAY EYE CARE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2012
Last Update Date: 08/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 W MAIN ST SUITE A
JOHN DAY OR
97845-1075
US

IV. Provider business mailing address

401 W MAIN ST SUITE A
JOHN DAY OR
97845-1075
US

V. Phone/Fax

Practice location:
  • Phone: 541-575-1819
  • Fax: 541-575-0965
Mailing address:
  • Phone: 541-575-1819
  • Fax: 541-575-0965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number3268ATI
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier023687
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: ASHLEY B HABERLY
Title or Position: SECRETARY
Credential:
Phone: 541-575-1819