=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033401062
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYE FOCUS NORTHWEST LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2011
-----------------------------------------------------
Last Update Date | 10/13/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3816 CENTER ST NE
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97301-2905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-588-5513
-----------------------------------------------------
Fax | 503-588-5470
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3816 CENTER ST NE
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97301-2905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-588-5513
-----------------------------------------------------
Fax | 503-588-5470
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MARK J FAST
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 503-588-5513
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OR2986ATI
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------