Healthcare Provider Details

I. General information

NPI: 1770972515
Provider Name (Legal Business Name): NORTHWEST OPTOMETRIC ASSOCIATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2015
Last Update Date: 01/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1522 SW SUNSET BLVD
PORTLAND OR
97239-2626
US

IV. Provider business mailing address

1522 SW SUNSET BLVD
PORTLAND OR
97239-2626
US

V. Phone/Fax

Practice location:
  • Phone: 503-473-8039
  • Fax: 503-473-8952
Mailing address:
  • Phone: 503-473-8039
  • Fax: 503-473-8952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2151ATI
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3023ATI
License Number StateOR

VIII. Authorized Official

Name: DR. MARI WARD
Title or Position: PRESIDENT
Credential: OD
Phone: 503-473-8039