Provider Demographics
NPI:1194092940
Name:WALLOWA VALLEY EYE CARE, INC.
Entity type:Organization
Organization Name:WALLOWA VALLEY EYE CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:O.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:TROY
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-426-3413
Mailing Address - Street 1:PO BOX L
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:OR
Mailing Address - Zip Code:97828-0227
Mailing Address - Country:US
Mailing Address - Phone:541-426-3413
Mailing Address - Fax:541-426-4889
Practice Address - Street 1:519 W. NORTH STREET
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:OR
Practice Address - Zip Code:97828-1168
Practice Address - Country:US
Practice Address - Phone:541-426-3413
Practice Address - Fax:541-426-4489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-22
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2557ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR275377Medicaid
OR275377Medicaid