Provider Demographics
NPI:1144556655
Name:JOANNA M GERVAIS OD LLC
Entity type:Organization
Organization Name:JOANNA M GERVAIS OD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOANNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GERVAIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:541-777-0245
Mailing Address - Street 1:1871 2ND ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-2121
Mailing Address - Country:US
Mailing Address - Phone:541-741-0122
Mailing Address - Fax:
Practice Address - Street 1:1871 2ND ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-2121
Practice Address - Country:US
Practice Address - Phone:541-741-0122
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-19
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332H00000X
OR3263AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty