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General NPI Number Information
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NPI Number | 1760894356
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Entity Type | Organization
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Legal Business Name | HERITAGE EYECARE
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Dates
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Enumeration Date | 05/29/2014
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Last Update Date | 07/10/2014
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Provider Practice Location Address
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Address Line | 2169 14TH AVE SE
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City | ALBANY
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State | OR
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Zip | 97322-8510
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Country | US
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Telephone | 541-926-2061
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Fax | 541-926-4845
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Provider Business Mailing Address
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Address Line | 2169 14TH AVE SE
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City | ALBANY
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State | OR
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Zip | 97322-8510
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Country | US
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Telephone | 541-926-2061
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Fax | 541-926-4845
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Authorized Official
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Title or Position | OPTOMETRIST/MANAGER
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Name | DR. ANALICIA NICOLE CZUPRYK
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Credential | OD
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Telephone | 503-701-2557
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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 | 3445ATI
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License Number State | OR
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