Basic Information
| Provider Information | |||||||||
| NPI: | 1104378140 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CLACKAMAS EYE CARE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 NE MULTNOMAH ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972322023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038132000 | ||||||||
| FaxNumber: | 5032866879 | ||||||||
| Practice Location | |||||||||
| Address1: | 12100 SE STEVENS CT | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970864707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008132000 | ||||||||
| FaxNumber: | 5032866879 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2016 | ||||||||
| LastUpdateDate: | 06/01/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BARTON | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | SHAWN | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR, REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 5038132440 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST | ||||||||
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| NPICertificationDate: | 06/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 156F00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Technician/Technologist | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.