MEDICARE: DR. AMI RENEE HALVORSON O.D.

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	152W00000X	Optometrist	OD00004138	WA
2	152W00000X	Optometrist	3218ATI	OR
3	152W00000X	Optometrist	OD4138	WA
4	152W00000X	Optometrist	ATI3218	OR

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G8934638	OTHER	WA	MEDICARE WA
2	G8934639	OTHER	WA	MEDICARE WA
3	G8934640	OTHER	WA	MEDICARE WA
4	G8934636	OTHER	WA	MEDICARE WA
7	G8934637	OTHER	WA	MEDICARE WA
8	R177569	OTHER	OR	MEDICARE OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447457452
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AMI RENEE HALVORSON O.D.

Provider Business Mailing Address
First Line	:	PO BOX 1506
Second Line	:
City	:	CHEHALIS
State	:	WA
Zip	:	98532-0409
Country	:	US
Telephone Number	:	360-242-3010
Fax Number	:

Provider Business Practice Location Address
First Line	:	1331 NW LOVEJOY ST STE 750
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97209-3281
Country	:	US
Telephone Number	:	503-535-2883
Fax Number	:	503-535-2887

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/02/2007
Last Update Date	:	11/19/2020

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