Provider Demographics
NPI:1891920674
Name:JACKSONVILLE VISION CLINIC INC
Entity Type:Organization
Organization Name:JACKSONVILLE VISION CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DANIELSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:541-899-2020
Mailing Address - Street 1:950 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97530-9016
Mailing Address - Country:US
Mailing Address - Phone:541-899-2020
Mailing Address - Fax:541-899-1481
Practice Address - Street 1:950 N 5TH ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97530-9016
Practice Address - Country:US
Practice Address - Phone:541-899-2020
Practice Address - Fax:541-899-1481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-21
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3036ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR210539Medicaid
ORU43970Medicare UPIN
OR1166230001Medicare NSC
ORR162474Medicare PIN