Healthcare Provider Details

I. General information

NPI: 1437203858
Provider Name (Legal Business Name): NORTHWEST EYE CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 01/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2435 NW KLINE ST
ROSEBURG OR
97471-1690
US

IV. Provider business mailing address

2435 NW KLINE ST
ROSEBURG OR
97471-1690
US

V. Phone/Fax

Practice location:
  • Phone: 541-672-2020
  • Fax: 541-673-8084
Mailing address:
  • Phone: 541-672-2020
  • Fax: 541-673-8084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. PAM D BELLIS
Title or Position: FINANCIAL COORDINATOR
Credential:
Phone: 541-672-2020