Healthcare Provider Details

I. General information

NPI: 1427919729
Provider Name (Legal Business Name): CONVERGE NEURO OPTOMETRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2025
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9975 SW FREWING ST STE 130
TIGARD OR
97223-5091
US

IV. Provider business mailing address

13010 SW CASPIAN CT
BEAVERTON OR
97008-7760
US

V. Phone/Fax

Practice location:
  • Phone: 503-906-3596
  • Fax: 503-906-1014
Mailing address:
  • Phone: 650-521-4570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number
License Number State

VIII. Authorized Official

Name: MACSON LEE
Title or Position: CEO, OD, FOVDRA
Credential: O.D.
Phone: 650-521-4570