Healthcare Provider Details

I. General information

NPI: 1316367303
Provider Name (Legal Business Name): CAPITOL EYE CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2014
Last Update Date: 01/27/2020
Certification Date: 01/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1960 COMMERCIAL ST SE
SALEM OR
97302-5206
US

IV. Provider business mailing address

1960 COMMERCIAL ST SE
SALEM OR
97302-5206
US

V. Phone/Fax

Practice location:
  • Phone: 503-363-9011
  • Fax: 503-362-6376
Mailing address:
  • Phone: 503-363-9011
  • Fax: 503-362-6376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2928ATI
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: DR. CHRISTOPHER BERRY
Title or Position: OWNER
Credential: OD
Phone: 503-363-9011