Healthcare Provider Details

I. General information

NPI: 1487786455
Provider Name (Legal Business Name): VISION PENDLETON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 09/29/2020
Certification Date: 09/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 SW EMIGRANT AVE
PENDLETON OR
97801-1843
US

IV. Provider business mailing address

1815 SW EMIGRANT AVE
PENDLETON OR
97801-1843
US

V. Phone/Fax

Practice location:
  • Phone: 541-276-3653
  • Fax: 541-966-4322
Mailing address:
  • Phone: 541-276-3653
  • Fax: 541-966-4322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2456ATI
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2399ATI
License Number StateOR

VIII. Authorized Official

Name: DR. MICHELLE M MONKMAN
Title or Position: OWNER
Credential: OD
Phone: 541-276-3653