Provider Demographics
NPI:1336142140
Name:CLOYD FAMILY VISION LLC
Entity Type:Organization
Organization Name:CLOYD FAMILY VISION LLC
Other - Org Name:RIVERSIDE VISION CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:FRANCES
Authorized Official - Middle Name:G
Authorized Official - Last Name:CLOYD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:541-776-3718
Mailing Address - Street 1:709 S RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-7837
Mailing Address - Country:US
Mailing Address - Phone:541-776-3718
Mailing Address - Fax:541-776-5928
Practice Address - Street 1:709 S RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-7837
Practice Address - Country:US
Practice Address - Phone:541-776-3718
Practice Address - Fax:541-776-5928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1754ATI152W00000X
OR1982ATI152W00000X
332B00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR080064Medicaid
OR002453OtherBLUECROSS BLUESHIELD OR
ORO5189OtherPACIFIC SOURCE HEALTH PLA
OR4003592OtherHMO OREGON
ORR0000WFBLTMedicare PIN
OR002453OtherBLUECROSS BLUESHIELD OR