Healthcare Provider Details

I. General information

NPI: 1831986124
Provider Name (Legal Business Name): KENNETH NGO
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2025
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

990 BROADWAY ST NE
SALEM OR
97301-1421
US

IV. Provider business mailing address

990 BROADWAY ST NE
SALEM OR
97301-1421
US

V. Phone/Fax

Practice location:
  • Phone: 503-364-0767
  • Fax: 503-581-8340
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4843AT
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: