Healthcare Provider Details

I. General information

NPI: 1902981087
Provider Name (Legal Business Name): EYECARE ASSOCIATES OF SOUTHERN OREGON PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 06/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

935 ROYAL AVE
MEDFORD OR
97504-6140
US

IV. Provider business mailing address

935 ROYAL AVE
MEDFORD OR
97504-6140
US

V. Phone/Fax

Practice location:
  • Phone: 541-779-2211
  • Fax: 541-779-8778
Mailing address:
  • Phone: 541-779-2211
  • Fax: 541-779-8778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3079AT
License Number StateOR

VIII. Authorized Official

Name: MR. BRIAN K MITCHELL
Title or Position: PRESIDENT
Credential: O. D.
Phone: 541-779-2211