Provider Demographics
NPI:1194940726
Name:EYEHEALTH NORTHWEST OPTICAL, LLC
Entity type:Organization
Organization Name:EYEHEALTH NORTHWEST OPTICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:WELLS
Authorized Official - Last Name:BENTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-557-2020
Mailing Address - Street 1:PO BOX 22009
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97269-2009
Mailing Address - Country:US
Mailing Address - Phone:503-344-5102
Mailing Address - Fax:503-344-5110
Practice Address - Street 1:11086 SE OAK ST
Practice Address - Street 2:ADMINISTRATION
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-6692
Practice Address - Country:US
Practice Address - Phone:503-344-5102
Practice Address - Fax:503-344-5110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1243050004OtherDURABLE MEDICAL EQUIPMENT
OR1243050002OtherDURABLE MEDICAL EQUIPMENT
OR1243050003OtherDURABLE MEDICAL EQUIPMENT
OR1243050006OtherDURABLE MEDICAL EQUIPMENT
OR1243050005OtherDURABLE MEDICAL EQUIPMENT
OR1243050001OtherDURABLE MEDICAL EQUIPMENT
OR1243050007OtherDURABLE MEDICAL EQUIPMENT