Provider Demographics
NPI:1174549364
Name:SUNSET EYE CLINIC LLC
Entity type:Organization
Organization Name:SUNSET EYE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNY
Authorized Official - Middle Name:B
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:503-533-8441
Mailing Address - Street 1:1865 NW 169TH PL
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-7327
Mailing Address - Country:US
Mailing Address - Phone:503-533-8441
Mailing Address - Fax:503-533-8403
Practice Address - Street 1:1865 NW 169TH PL
Practice Address - Street 2:SUITE 105
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-7327
Practice Address - Country:US
Practice Address - Phone:503-533-8441
Practice Address - Fax:503-533-8403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2877ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR270841Medicaid
ORR132728Medicare ID - Type Unspecified
OR270841Medicaid