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General NPI Number Information
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NPI Number | 1215213335
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Entity Type | Organization
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Legal Business Name | SHASTA EYECARE ASSOCIATES, LLC
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Dates
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Enumeration Date | 11/03/2011
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Last Update Date | 11/03/2011
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Provider Practice Location Address
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Address Line | 2655 SHASTA WAY
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City | KLAMATH FALLS
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State | OR
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Zip | 97603-4455
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Country | US
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Telephone | 541-882-7083
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Fax | 541-882-4228
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Provider Business Mailing Address
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Address Line | 2655 SHASTA WAY
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City | KLAMATH FALLS
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State | OR
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Zip | 97603-4455
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Country | US
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Telephone | 541-882-7083
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Fax | 541-882-4228
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Authorized Official
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Title or Position | OWNER
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Name | DR. RICHARD HARRISON
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Credential | O.D.
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Telephone | 912-506-6596
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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 | 3429ATI
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License Number State | OR
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