Healthcare Provider Details

I. General information

NPI: 1124466545
Provider Name (Legal Business Name): URBAN EYE GALLERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2013
Last Update Date: 06/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 SW 16TH AVE
PORTLAND OR
97205-1730
US

IV. Provider business mailing address

921 SW 16TH AVE
PORTLAND OR
97205-1730
US

V. Phone/Fax

Practice location:
  • Phone: 503-227-0573
  • Fax:
Mailing address:
  • Phone: 503-227-0573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3195 ATI
License Number StateOR

VIII. Authorized Official

Name: ANITA PHROMSIVARAK BACON
Title or Position: MANAGING MEMBER
Credential: O.D.
Phone: 503-227-0573