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Individual

ANITA (ANNIE) PHROMSIVARAK BACON

Active
Sole proprietor
No

Provider details

NPI number
Gender
F
Credential
O.D.

Contact information

Practice address
921 SW 16TH AVE, PORTLAND, OR 97205-1730
(503) 227-0573
Mailing address
921 SW 16TH AVE, PORTLAND, OR 97205-1730
(503) 227-0573

Taxonomy

Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
3195AT
OR

Other

Enumeration date
02/09/2007
Last updated
05/21/2013
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