Healthcare Provider Details

I. General information

NPI: 1235325176
Provider Name (Legal Business Name): LIGHTHOUSE VISION CARE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2007
Last Update Date: 09/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 STILLWELL AVE
TILLAMOOK OR
97141-2119
US

IV. Provider business mailing address

310 STILLWELL AVE
TILLAMOOK OR
97141-2119
US

V. Phone/Fax

Practice location:
  • Phone: 503-842-6363
  • Fax: 503-842-6204
Mailing address:
  • Phone: 503-842-6363
  • Fax: 503-842-6204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2858T
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number2858T
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number2858T
License Number StateOR

VIII. Authorized Official

Name: DR. RAYMOND K DEHAAN
Title or Position: OPTOMETRIST/PRESIDENT
Credential: O.D.
Phone: 503-842-6363