Healthcare Provider Details

I. General information

NPI: 1750437067
Provider Name (Legal Business Name): CLAYTON M BRISCOE O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 SW EMIGRANT AVE
PENDLETON OR
97801-1843
US

IV. Provider business mailing address

1815 SW EMIGRANT AVE
PENDLETON OR
97801-1843
US

V. Phone/Fax

Practice location:
  • Phone: 541-276-3653
  • Fax: 541-966-4322
Mailing address:
  • Phone: 541-276-3653
  • Fax: 541-966-4322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2399ATI
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: