Provider Demographics
NPI:1538429816
Name:EYEGLASS FACTORY
Entity type:Organization
Organization Name:EYEGLASS FACTORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OD/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:HALE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:541-754-6222
Mailing Address - Street 1:1505 NW HARRISON BLVD
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-5816
Mailing Address - Country:US
Mailing Address - Phone:541-754-6222
Mailing Address - Fax:541-757-2055
Practice Address - Street 1:1885 25TH ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-1105
Practice Address - Country:US
Practice Address - Phone:503-588-2395
Practice Address - Fax:503-588-8011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-21
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2674ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
R132649Medicare UPIN
R109920Medicare UPIN
R161117Medicare UPIN
R109919Medicare UPIN