=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801587860
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID WETHERELL ABOC, NCLEC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2023
-----------------------------------------------------
Last Update Date | 05/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2203 SW COURT PL
-----------------------------------------------------
City | PENDLETON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97801-1896
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-276-2905
-----------------------------------------------------
Fax | 541-276-2918
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2203 SW COURT PL
-----------------------------------------------------
City | PENDLETON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97801-1896
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-276-2905
-----------------------------------------------------
Fax | 541-276-2918
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | 216334
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------