Provider Demographics
NPI:1154691830
Name:FOREST GROVE MEDICAL PC
Entity type:Organization
Organization Name:FOREST GROVE MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:C
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:503-357-2020
Mailing Address - Street 1:PO BOX 38
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-0038
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:2012-01-11
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty