Provider Demographics
NPI:1285824417
Name:ABC OPTOMETRIC PC
Entity type:Organization
Organization Name:ABC OPTOMETRIC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SEC./TREAS.
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HESTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-473-8039
Mailing Address - Street 1:2991 SE 75TH AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-6210
Mailing Address - Country:US
Mailing Address - Phone:503-649-7566
Mailing Address - Fax:503-649-0123
Practice Address - Street 1:2991 SE 75TH AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-6210
Practice Address - Country:US
Practice Address - Phone:503-649-7566
Practice Address - Fax:503-649-0123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2784ATI152W00000X
152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR226366Medicaid