1407898026 NPI number — BAY OPTICAL LABORATORY CORP.

Table of content: (NPI 1407898026)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407898026 NPI number — BAY OPTICAL LABORATORY CORP.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BAY OPTICAL LABORATORY CORP.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407898026
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3587 BROADWAY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH BEND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97459-1251
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-756-2571
Provider Business Mailing Address Fax Number:
541-756-3976

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3587 BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH BEND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97459-1251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-756-2571
Provider Business Practice Location Address Fax Number:
541-756-3976
Provider Enumeration Date:
06/11/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
VAN ELSBERG
Authorized Official First Name:
LILY
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
ASSISTANT MANAGER/BOOKKEEPER
Authorized Official Telephone Number:
541-756-2571

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 012641 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0009759000 . This is a "PROVIDER NUMBER" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".