Provider Demographics
NPI:1144847260
Name:PARKROSE VISION, LLC
Entity type:Organization
Organization Name:PARKROSE VISION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HALEY
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:503-432-8452
Mailing Address - Street 1:15470 SE BADEN POWELL RD
Mailing Address - Street 2:
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086-6049
Mailing Address - Country:US
Mailing Address - Phone:503-819-1807
Mailing Address - Fax:503-432-8402
Practice Address - Street 1:4880 NE 104TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220
Practice Address - Country:US
Practice Address - Phone:503-943-0699
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:M. KWON. P.C., INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-07-06
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500784142Medicaid