Provider Demographics
NPI:1386786309
Name:EYE CARE GROUP OF SOUTHERN OREGON, LLC
Entity type:Organization
Organization Name:EYE CARE GROUP OF SOUTHERN OREGON, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:PELSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:541-592-3921
Mailing Address - Street 1:335 CAVES HIGHWAY
Mailing Address - Street 2:PO BOX 448
Mailing Address - City:CAVE JUNCTION
Mailing Address - State:OR
Mailing Address - Zip Code:97523
Mailing Address - Country:US
Mailing Address - Phone:541-592-3921
Mailing Address - Fax:541-592-4883
Practice Address - Street 1:335 CAVES HIGHWAY
Practice Address - Street 2:
Practice Address - City:CAVE JUNCTION
Practice Address - State:OR
Practice Address - Zip Code:97523
Practice Address - Country:US
Practice Address - Phone:541-592-3921
Practice Address - Fax:541-592-4883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR005730Medicaid
OR005730Medicaid