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General NPI Number Information
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NPI Number | 1104483833
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Entity Type | Individual
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Provider Name | HALEY KIM OD
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Gender | Female
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Dates
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Enumeration Date | 05/29/2019
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Last Update Date | 05/22/2024
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Provider Practice Location Address
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Address Line | 4880 NE 104TH AVE
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City | PORTLAND
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State | OR
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Zip | 97220-3348
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Country | US
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Telephone | 503-432-8452
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Fax | 503-432-8402
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Provider Business Mailing Address
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Address Line | 4880 NE 104TH AVE
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City | PORTLAND
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State | OR
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Zip | 97220-3348
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Country | US
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Telephone | 503-432-8452
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Fax | 503-432-8402
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | ATI4521
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License Number State | OR
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