=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548946742
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VISION PERFORMANCE OF OREGON LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2023
-----------------------------------------------------
Last Update Date | 05/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7129 NE IMBRIE DR
-----------------------------------------------------
City | HILLSBORO
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97124-7594
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-690-2020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1500 SW 11TH AVE UNIT 207
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97201-3532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-516-7989
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | SHUN-NAN YANG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 503-690-2020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------