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General NPI Number Information
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NPI Number | 1235325176
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Entity Type | Organization
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Legal Business Name | LIGHTHOUSE VISION CARE, P.C.
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Dates
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Enumeration Date | 09/24/2007
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Last Update Date | 09/24/2007
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Provider Practice Location Address
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Address Line | 310 STILLWELL AVE
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City | TILLAMOOK
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State | OR
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Zip | 97141-2119
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Country | US
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Telephone | 503-842-6363
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Fax | 503-842-6204
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Provider Business Mailing Address
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Address Line | 310 STILLWELL AVE
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City | TILLAMOOK
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State | OR
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Zip | 97141-2119
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Country | US
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Telephone | 503-842-6363
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Fax | 503-842-6204
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Authorized Official
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Title or Position | OPTOMETRIST/PRESIDENT
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Name | DR. RAYMOND K DEHAAN
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Credential | O.D.
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Telephone | 503-842-6363
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152WP0200X
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Taxonomy Name | Pediatric Optometrist
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License Number | 2858T
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 152WC0802X
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Taxonomy Name | Corneal and Contact Management Optometrist
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License Number | 2858T
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License Number State | OR
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Taxonomy #3
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2858T
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License Number State | OR
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