Basic Information
| Provider Information | |||||||||
| NPI: | 1366510034 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEDICAL EYE CENTER OPTICAL INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1333 E BARNETT RD | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975048219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417794711 | ||||||||
| FaxNumber: | 5416181485 | ||||||||
| Practice Location | |||||||||
| Address1: | 1333 E BARNETT RD | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975048219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417794711 | ||||||||
| FaxNumber: | 5416181485 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| LastUpdateDate: | 01/14/2011 | ||||||||
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| AuthorizedOfficialLastName: | CASEBOLT | ||||||||
| AuthorizedOfficialFirstName: | KEITH | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5417794711 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
ID Information
| ID | Type | State | Issuer | Description | 040654 | 05 | OR | MEDICAID |