Healthcare Provider Details

I. General information

NPI: 1750362869
Provider Name (Legal Business Name): EYE HEALTH EASTSIDE SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 04/05/2022
Certification Date: 04/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12050 SE STEVENS RD STE 400
PORTLAND OR
97086-7667
US

IV. Provider business mailing address

PO BOX 220059
MILWAUKIE OR
97269-0059
US

V. Phone/Fax

Practice location:
  • Phone: 971-206-6100
  • Fax: 971-206-6103
Mailing address:
  • Phone: 503-558-7372
  • Fax: 503-344-5140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number07-1553
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number07-1553
License Number StateOR

VIII. Authorized Official

Name: BRETT WILLIAMS
Title or Position: CEO
Credential:
Phone: 503-344-5101