=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295158301
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OIZU OPTIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2014
-----------------------------------------------------
Last Update Date | 01/24/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4133 SE DIVISION ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97202-1646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-444-7639
-----------------------------------------------------
Fax | 503-972-1593
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4133 SE DIVISION ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97202-1646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-444-7639
-----------------------------------------------------
Fax | 503-972-1593
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | DR. SAMUEL ADELMAN
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 503-660-3093
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152WC0802X
-----------------------------------------------------
Taxonomy Name | Corneal and Contact Management Optometrist
-----------------------------------------------------
License Number | 3462ATI
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152WP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Optometrist
-----------------------------------------------------
License Number | 3462ATI
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 152WS0006X
-----------------------------------------------------
Taxonomy Name | Sports Vision Optometrist
-----------------------------------------------------
License Number | 3462ATI
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 152WV0400X
-----------------------------------------------------
Taxonomy Name | Vision Therapy Optometrist
-----------------------------------------------------
License Number | 3462ATI
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 152WX0102X
-----------------------------------------------------
Taxonomy Name | Occupational Vision Optometrist
-----------------------------------------------------
License Number | 3462ATI
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 3462ATI
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------