Healthcare Provider Details

I. General information

NPI: 1164791414
Provider Name (Legal Business Name): MADRAS VISION SOURCE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2011
Last Update Date: 05/17/2022
Certification Date: 05/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 SE 5TH ST
MADRAS OR
97741
US

IV. Provider business mailing address

211 SE 5TH ST
MADRAS OR
97741
US

V. Phone/Fax

Practice location:
  • Phone: 541-475-2020
  • Fax: 541-475-6118
Mailing address:
  • Phone: 541-475-2020
  • Fax: 541-475-6118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3215ATI
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: JESSICA BROOKE TEGAN
Title or Position: OWNER
Credential: OD
Phone: 541-475-2020