Provider Demographics
NPI:1124332069
Name:FOREST GROVE FAMILY EYE CARE, P.C.
Entity type:Organization
Organization Name:FOREST GROVE FAMILY EYE CARE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ELI
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:503-357-2020
Mailing Address - Street 1:PO BOX 847
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-0847
Mailing Address - Country:US
Mailing Address - Phone:503-357-2020
Mailing Address - Fax:503-357-6995
Practice Address - Street 1:2804 19TH AVE
Practice Address - Street 2:
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-2625
Practice Address - Country:US
Practice Address - Phone:503-357-2020
Practice Address - Fax:503-357-6995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-03
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3381ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty