Provider Demographics
NPI:1649355520
Name:VAN HORN, CHERYL COLLEEN (OD)
Entity type:Individual
Prefix:DR
First Name:CHERYL
Middle Name:COLLEEN
Last Name:VAN HORN
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 1:717 FAIRMONT AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-5135
Mailing Address - Country:US
Mailing Address - Phone:304-366-3830
Mailing Address - Fax:304-366-8049
Practice Address - Street 1:717 FAIRMONT AVE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-5135
Practice Address - Country:US
Practice Address - Phone:304-366-3830
Practice Address - Fax:304-366-8049
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV853-OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0149347000Medicaid
WV9927631OtherMEDICARE PTAN
WV001719073OtherBLUE CROSS NUMBER
WV0867551OtherUMWA FUNDS
WV0149347000Medicaid
WV9927631OtherMEDICARE PTAN