Healthcare Provider Details

I. General information

NPI: 1194708511
Provider Name (Legal Business Name): TIMOTHY DALE HORNER OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 09/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

536 BULWER ST
WHEELERSBURG OH
45694-1907
US

IV. Provider business mailing address

536 BULWER ST PO BOX 158
WHEELERSBURG OH
45694-1907
US

V. Phone/Fax

Practice location:
  • Phone: 740-574-4745
  • Fax: 740-574-5144
Mailing address:
  • Phone: 740-574-4745
  • Fax: 740-574-5144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3321 T1247
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: