MEDICARE: NILS KOFOED

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	ATI4514	OR

General Provider Information

NPI Number	:	1649895681
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NILS KOFOED

Provider Business Mailing Address
First Line	:	16752 SE MARKET ST # B
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97233-4426
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	23500 NE SANDY BLVD
Second Line	:
City	:	WOOD VILLAGE
State	:	OR
Zip	:	97060-9653
Country	:	US
Telephone Number	:	503-667-8869
Fax Number	:

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

Provider Enumeration Date	:	06/16/2020
Last Update Date	:	09/17/2021

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Directions to “ NILS KOFOED ” Practice Location

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