Healthcare Provider Details

I. General information

NPI: 1467434209
Provider Name (Legal Business Name): EYE HEALTH NORTHWEST OPTICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 09/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5050 NE HOYT ST SUITE 200
PORTLAND OR
97213-2991
US

IV. Provider business mailing address

PO BOX 22009
MILWAUKIE OR
97269-2009
US

V. Phone/Fax

Practice location:
  • Phone: 503-255-2291
  • Fax: 503-252-1797
Mailing address:
  • Phone: 503-557-2020
  • Fax: 503-344-5110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT WELLS BENTLEY
Title or Position: PRESIDENT
Credential: MD
Phone: 503-557-2020