=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285679878
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BEN E. COUTANT O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2006
-----------------------------------------------------
Last Update Date | 06/23/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2659 OLYMPIC ST
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97477-3473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-744-6973
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4815 WILLAMETTE ST
-----------------------------------------------------
City | EUGENE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97405-4835
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-556-9425
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2867ATI
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------