Healthcare Provider Details

I. General information

NPI: 1801973110
Provider Name (Legal Business Name): HIGH DESERT EYECARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

443 SW EVERGREEN AVE
REDMOND OR
97756-2817
US

IV. Provider business mailing address

PO BOX 918
REDMOND OR
97756-0206
US

V. Phone/Fax

Practice location:
  • Phone: 541-923-2221
  • Fax: 541-923-3776
Mailing address:
  • Phone: 541-923-2221
  • Fax: 541-923-3776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2601AT
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: ALISHIA DAWN HOLLAND
Title or Position: CREDENTIALING SPECIALIST
Credential: CPOA, CPOC, VSR
Phone: 541-923-2221