=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992870604
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RAINBOW OPTICS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2006
-----------------------------------------------------
Last Update Date | 06/28/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1740 W 18TH AVE
-----------------------------------------------------
City | EUGENE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97402-3625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-343-5555
-----------------------------------------------------
Fax | 541-334-7605
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1740 W 18TH AVE
-----------------------------------------------------
City | EUGENE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97402-3625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-343-5555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DARAN M DECALESTA
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 541-343-5555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------