=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992783468
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANN ADELE EASLY-DEBISSCHOP O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2006
-----------------------------------------------------
Last Update Date | 02/08/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 279 SW 10TH ST
-----------------------------------------------------
City | ONTARIO
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97914-2135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-889-2020
-----------------------------------------------------
Fax | 541-889-9675
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 220
-----------------------------------------------------
City | ONTARIO
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97914-0220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-889-2020
-----------------------------------------------------
Fax | 541-889-9675
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1686AT
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------