NPIMap

Organization Active NPI

Molalla Vision Clinic PC

  • Optometrist
  • Molalla, OR
National Provider Identifier
1497931018
Registry record updated May 11, 2009
On this page

Key facts

NPPES NPI Registry
Primary specialty
OptometristTaxonomy code 152W00000X
License
2487ATI Issued in OR
Legal business name
MOLALLA VISION CLINIC PC
Practice address
502 E Main St
Molalla, OR 97038-9148
Phone
(503) 829-9186
Fax
(503) 829-8402
NPI assigned
Jan 14, 2008
Last updated
May 11, 2009By the provider in NPPES
Organization subpart
Yes
Parent organization
J. WALLACE WALKER ODAs reported in NPPES

NPPES NPI Registry

Updated by the provider on May 11, 2009

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Jay Wallace Walker, ODNPI 1235231275
Title
Owner
Phone
(503) 829-9186

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Optometrist 152W00000X 2487ATI OR Primary

Addresses

Primary practice location

502 E Main St
Molalla, OR 97038-9148

Mailing address

PO Box 480
Molalla, OR 97038-0480
Phone (503) 829-9186

Other identifiers 1

IdentifierTypeStateIssuer
260661MedicaidOR

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OR2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20090518000386 OR Part B Supplier - Clinic/Group Practice 9335298504 Receives reassigned benefits from 7 practitioners
Practice locations: Milwaukie, OR; Molalla, OR
O20100930001985 OR DME Supplier - Physician - OptometristDME Supplier - Optician 9335298504 Practice locations: Molalla, OR

National Provider Directory

National Provider Directory
Part of
Molalla Vision Clinic PC

Locations

405 NE Main St
Estacada, OR 97023
Phone (503) 630-3528

Practitioners & affiliated clinicians

Practitioners 8

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1200268800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1242000000000",
    "number": "1497931018",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 480",
            "city": "MOLALLA",
            "state": "OR",
            "postal_code": "970380480",
            "telephone_number": "503-829-9186",
            "fax_number": "503-829-8402"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "502 E MAIN ST",
            "city": "MOLALLA",
            "state": "OR",
            "postal_code": "970389148",
            "telephone_number": "503-829-9186",
            "fax_number": "503-829-8402"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MOLALLA VISION CLINIC PC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "J. WALLACE WALKER OD",
        "enumeration_date": "2008-01-14",
        "last_updated": "2009-05-11",
        "status": "A",
        "authorized_official_last_name": "WALKER",
        "authorized_official_first_name": "JAY",
        "authorized_official_middle_name": "WALLACE",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "503-829-9186",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "OD"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "",
            "desc": "Optometrist",
            "state": "OR",
            "license": "2487ATI",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "260661",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Molalla, OR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 11, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.