MEDICARE: JACKSONVILLE VISION CLINIC INC

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	3036ATI	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

General Provider Information

NPI Number	:	1891920674
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSONVILLE VISION CLINIC INC

Provider Business Mailing Address
First Line	:	950 N 5TH ST
Second Line	:
City	:	JACKSONVILLE
State	:	OR
Zip	:	97530-9016
Country	:	US
Telephone Number	:	541-899-2020
Fax Number	:	541-899-1481

Provider Business Practice Location Address
First Line	:	950 N 5TH ST
Second Line	:
City	:	JACKSONVILLE
State	:	OR
Zip	:	97530-9016
Country	:	US
Telephone Number	:	541-899-2020
Fax Number	:	541-899-1481

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	JULIE DANIELSON
Credential	:	O.D.
Telephone Number	:	541-899-2020

Provider Enumeration Date	:	05/21/2009
Last Update Date	:	05/03/2012

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Directions to “JACKSONVILLE VISION CLINIC INC ” Practice Location

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