Provider Demographics
NPI:1447280490
Name:GRESHAM VISION CENTER, INC
Entity type:Organization
Organization Name:GRESHAM VISION CENTER, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-665-3813
Mailing Address - Street 1:39400 PIONEER BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:OR
Mailing Address - Zip Code:97055-8000
Mailing Address - Country:US
Mailing Address - Phone:503-668-4313
Mailing Address - Fax:503-668-5963
Practice Address - Street 1:39400 PIONEER BLVD STE 3
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:OR
Practice Address - Zip Code:97055-8000
Practice Address - Country:US
Practice Address - Phone:503-668-4313
Practice Address - Fax:503-668-5963
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRESHAM VISION CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-04
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT67476152W00000X
OR1627ATI152W00000X
OR2474ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022759Medicaid
ORT67476Medicare UPIN
OR1447280490Medicare NSC
OR022759Medicaid
ORU44761Medicare UPIN