Healthcare Provider Details

I. General information

NPI: 1174705438
Provider Name (Legal Business Name): ADVANCED FAMILY EYECARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2007
Last Update Date: 08/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2245 LONG ST
SWEET HOME OR
97386-2845
US

IV. Provider business mailing address

38661 PALMYRE DR
LEBANON OR
97355-9284
US

V. Phone/Fax

Practice location:
  • Phone: 541-367-2188
  • Fax: 541-367-2189
Mailing address:
  • Phone: 541-401-4649
  • Fax: 541-367-2189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2480ATI
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number2480ATI
License Number StateOR

VIII. Authorized Official

Name: MICHAEL WAYNE STONER
Title or Position: OWNER/ DOCTOR
Credential: O.D.
Phone: 541-367-2188