Healthcare Provider Details

I. General information

NPI: 1508149063
Provider Name (Legal Business Name): MODERN EYEZ INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2011
Last Update Date: 10/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18750 WILLAMETTE DR STE C
WEST LINN OR
97068-1700
US

IV. Provider business mailing address

18750 WILLAMETTE DR STE C
WEST LINN OR
97068-1700
US

V. Phone/Fax

Practice location:
  • Phone: 503-697-8879
  • Fax:
Mailing address:
  • Phone: 503-697-8879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3272ATI
License Number StateOR

VIII. Authorized Official

Name: DR. ANN WOODS
Title or Position: OWNER
Credential: OD
Phone: 503-312-6464