MEDICARE: MYOPTIC OPTOMETRY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	305S00000X	Point of Service	3153AT	OR

General Provider Information

NPI Number	:	1235325333
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MYOPTIC OPTOMETRY, LLC

Provider Business Mailing Address
First Line	:	3978 N WILLIAMS AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97227-1445
Country	:	US
Telephone Number	:	503-493-7070
Fax Number	:	503-715-0504

Provider Business Practice Location Address
First Line	:	3333 SE BELMONT ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97214-4244
Country	:	US
Telephone Number	:	503-335-7173
Fax Number	:	503-335-7973

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	DR. YUESUM TO
Credential	:	O.D.
Telephone Number	:	503-493-7070

Provider Enumeration Date	:	09/21/2007
Last Update Date	:	04/21/2010

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