MEDICARE: CLOYD FAMILY VISION LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1982ATI	OR
2	332H00000X	Eyewear Supplier
3	332B00000X	Durable Medical Equipment & Medical Supplies
4	152W00000X	Optometrist	1754ATI	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	002453	OTHER	OR	BLUECROSS BLUESHIELD OR
3	O5189	OTHER	OR	PACIFIC SOURCE HEALTH PLA
4	4003592	OTHER	OR	HMO OREGON

General Provider Information

NPI Number	:	1336142140
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLOYD FAMILY VISION LLC

Provider Business Mailing Address
First Line	:	709 S RIVERSIDE AVE
Second Line	:
City	:	MEDFORD
State	:	OR
Zip	:	97501-7837
Country	:	US
Telephone Number	:	541-776-3718
Fax Number	:	541-776-5928

Provider Business Practice Location Address
First Line	:	709 S RIVERSIDE AVE
Second Line	:
City	:	MEDFORD
State	:	OR
Zip	:	97501-7837
Country	:	US
Telephone Number	:	541-776-3718
Fax Number	:	541-776-5928

Authorized Official
Title or Position	:	MEMBER
Name	:	FRANCES G CLOYD
Credential	:	O.D.
Telephone Number	:	541-776-3718

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	02/14/2008

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Directions to “CLOYD FAMILY VISION LLC ” Practice Location

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