=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568516953
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HORNER FAMILY EYECARE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2007
-----------------------------------------------------
Last Update Date | 04/04/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8360 CITY CENTRE DRIVE #140
-----------------------------------------------------
City | WOODBURY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-714-2015
-----------------------------------------------------
Fax | 651-714-2010
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8360 CITY CENTRE DRIVE #140
-----------------------------------------------------
City | WOODBURY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-714-2015
-----------------------------------------------------
Fax | 651-714-2010
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JOHN PATRICK HORNER
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 651-714-2015
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2089
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------