Healthcare Provider Details

I. General information

NPI: 1356952808
Provider Name (Legal Business Name): LACIE CATHERINE SPAGNOLA OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LACIE CATHERINE WATSON BS

II. Dates (important events)

Enumeration Date: 08/10/2020
Last Update Date: 09/08/2020
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1257 SW 4TH AVE
ONTARIO OR
97914-4516
US

IV. Provider business mailing address

1257 SW 4TH AVE
ONTARIO OR
97914-4516
US

V. Phone/Fax

Practice location:
  • Phone: 541-889-2191
  • Fax: 541-881-1523
Mailing address:
  • Phone: 541-889-2191
  • Fax: 541-881-1523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4539
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: