Healthcare Provider Details

I. General information

NPI: 1598001844
Provider Name (Legal Business Name): EAGLE EYE VISION CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2012
Last Update Date: 12/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4048 RIVER ROAD NORTH
KEIZER OR
97303
US

IV. Provider business mailing address

4048 RIVER RD N
KEIZER OR
97303-5501
US

V. Phone/Fax

Practice location:
  • Phone: 503-385-8361
  • Fax: 503-385-8364
Mailing address:
  • Phone: 503-385-8361
  • Fax: 503-385-8364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3288ATI
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DR. KEIRSTEN DANEE EAGLES
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 503-385-8361