MEDICARE: BAKER 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	1773ATI	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	:	1013063676
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAKER VISION CLINIC, INC.

Provider Business Mailing Address
First Line	:	2150 3RD ST
Second Line	:
City	:	BAKER CITY
State	:	OR
Zip	:	97814-2609
Country	:	US
Telephone Number	:	541-523-5858
Fax Number	:	541-523-7652

Provider Business Practice Location Address
First Line	:	2150 3RD ST
Second Line	:
City	:	BAKER CITY
State	:	OR
Zip	:	97814-2609
Country	:	US
Telephone Number	:	541-523-5858
Fax Number	:	541-523-7652

Authorized Official
Title or Position	:	CO-OWNER
Name	:	DR. SHERYL K BLANKENSHIP
Credential	:	O.D.
Telephone Number	:	541-523-5858

Provider Enumeration Date	:	01/26/2007
Last Update Date	:	10/05/2010

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