=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184387532
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEGANEKO LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2021
-----------------------------------------------------
Last Update Date | 11/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7826 SW CAPITOL HWY
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97219-2466
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-863-0657
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7826 SW CAPITOL HWY
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97219-2466
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-244-7788
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | AYLA JADE HIMMELSBACH
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 503-863-0657
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------