Healthcare Provider Details

I. General information

NPI: 1649895681
Provider Name (Legal Business Name): NILS KOFOED
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2020
Last Update Date: 09/17/2021
Certification Date: 09/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23500 NE SANDY BLVD
WOOD VILLAGE OR
97060-9653
US

IV. Provider business mailing address

16752 SE MARKET ST # B
PORTLAND OR
97233-4426
US

V. Phone/Fax

Practice location:
  • Phone: 503-667-8869
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberATI4514
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: