Provider Demographics
NPI:1427919729
Name:CONVERGE NEURO OPTOMETRY LLC
Entity type:Organization
Organization Name:CONVERGE NEURO OPTOMETRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO, OD, FOVDRA
Authorized Official - Prefix:
Authorized Official - First Name:MACSON
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:650-521-4570
Mailing Address - Street 1:13010 SW CASPIAN CT
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008-7760
Mailing Address - Country:US
Mailing Address - Phone:650-521-4570
Mailing Address - Fax:
Practice Address - Street 1:9975 SW FREWING ST STE 130
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-5091
Practice Address - Country:US
Practice Address - Phone:503-906-3596
Practice Address - Fax:503-906-1014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-11-18
Last Update Date:2025-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Multi-Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty