Provider Demographics
NPI:1407966203
Name:HORN OPTOMETRIC, LLC
Entity Type:Organization
Organization Name:HORN OPTOMETRIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIC MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:CLAIR-HORN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:541-779-3797
Mailing Address - Street 1:235 E BARNETT RD STE 108
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-7903
Mailing Address - Country:US
Mailing Address - Phone:541-779-3797
Mailing Address - Fax:541-779-3797
Practice Address - Street 1:235 E BARNETT RD STE 108
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-7903
Practice Address - Country:US
Practice Address - Phone:541-779-3797
Practice Address - Fax:541-779-3797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3092T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR241391Medicaid
OR241391Medicaid