Gresham Vision Center, Inc
Organization Active NPI Optometrist · Sandy, OR
NPI 1447280490 · NPPES record last updated Mar 19, 2015
Key facts
- NPI
- 1447280490
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Optometrist 152W00000X
- License
- T67476 (OR)
- Legal business name
- GRESHAM VISION CENTER, INC
- Practice address
- 39400 Pioneer Blvd Ste 3
Sandy, OR 97055-8000 - Phone
- (503) 668-4313
- Fax
- (503) 668-5963
- NPI assigned
- Jul 4, 2006
- Organization subpart
- Yes
- Parent organization (as reported)
- GRESHAM VISION CENTER
Authorized official
- Name
- Diane Gardner
- Title
- Office Manager
- Phone
- (503) 665-3813
Other NPIs on the same Medicare enrollment 1
Practitioners 6
-
Nancy Brock, O.D.
-
Patrick Kwong, OD
-
Tina Jeo, O.D.
-
Catherine B Saul, OD
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in OR
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040813000274 | OR | Part B Supplier - Clinic/Group Practice | 8820061401 |
Receives reassigned benefits from 5 practitioners 1 other NPI on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Gresham, OR; Sandy, OR |
National Provider Directory
- Part of
- Gresham Vision Center Inc
Locations
125 NW Miller Ave
Gresham, OR 97030
Phone (503) 665-3813
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist |
152W00000X | T67476 | OR | Yes |
| Optometrist |
152W00000X | 1627ATI | OR | |
| Optometrist |
152W00000X | 2474ATI | OR |
Addresses
Primary practice location
39400 Pioneer Blvd Ste 3
Sandy, OR 97055-8000
Mailing address
39400 Pioneer Blvd Ste 3
Sandy, OR 97055-8000
Phone (503) 668-4313
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 022759 | Medicaid | OR |
Other names
- sandy vision center
Other providers in Sandy, OR
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 19, 2015. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.