Provider Demographics
NPI:1902981087
Name:EYECARE ASSOCIATES OF SOUTHERN OREGON PC
Entity Type:Organization
Organization Name:EYECARE ASSOCIATES OF SOUTHERN OREGON PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:O D
Authorized Official - Phone:541-779-2211
Mailing Address - Street 1:935 ROYAL AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6140
Mailing Address - Country:US
Mailing Address - Phone:541-779-2211
Mailing Address - Fax:541-779-8778
Practice Address - Street 1:935 ROYAL AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6140
Practice Address - Country:US
Practice Address - Phone:541-779-2211
Practice Address - Fax:541-779-8778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3079AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR026488Medicaid
OR229948Medicaid
OR064886Medicaid
ORR115635Medicare PIN
ORU50440Medicare UPIN
ORR135334Medicare PIN
ORR115636Medicare PIN
OR026488Medicaid