Provider Demographics
NPI:1619211240
Name:PROGRESSIVE OPTOMETRY, INC.
Entity type:Organization
Organization Name:PROGRESSIVE OPTOMETRY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:S
Authorized Official - Last Name:DUKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-552-0677
Mailing Address - Street 1:2325 ASHLAND ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-1407
Mailing Address - Country:US
Mailing Address - Phone:541-552-0677
Mailing Address - Fax:541-552-0679
Practice Address - Street 1:2325 ASHLAND ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-1407
Practice Address - Country:US
Practice Address - Phone:541-552-0677
Practice Address - Fax:541-552-0679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2413152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150874Medicaid
OR150874Medicaid