Provider Demographics
NPI:1235464314
Name:CLAYTON, BREENA DELL (OD)
Entity Type:Individual
Prefix:
First Name:BREENA
Middle Name:DELL
Last Name:CLAYTON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13650 ELDER DR
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425-8818
Mailing Address - Country:US
Mailing Address - Phone:218-855-5756
Mailing Address - Fax:218-855-5753
Practice Address - Street 1:13650 ELDER DR
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-8818
Practice Address - Country:US
Practice Address - Phone:218-855-5756
Practice Address - Fax:218-855-5753
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-07
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN3328152W00000X
OR3467ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program