Healthcare Provider Details

I. General information

NPI: 1306446513
Provider Name (Legal Business Name): AD ASTRA OPTOMETRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2020
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 E 2ND ST
THE DALLES OR
97058-2107
US

IV. Provider business mailing address

301 E 2ND ST
THE DALLES OR
97058-2107
US

V. Phone/Fax

Practice location:
  • Phone: 541-769-1150
  • Fax:
Mailing address:
  • Phone: 541-769-1150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. JENESSA L HARTMAN
Title or Position: OWNER
Credential: OD
Phone: 541-370-1437