1891985453 NPI number — CHRISTOPHER CARMIENCKE OD

Table of content: BRITTANY NICOLE BODO OD (NPI 1881324002)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891985453 NPI number — CHRISTOPHER CARMIENCKE OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHRISTOPHER CARMIENCKE OD
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:
INTEGRATED EYECARE
Provider Other Organization Name Type Code:
5
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:
1891985453
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
452 NE GREENWOOD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97701-4608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-382-5701
Provider Business Mailing Address Fax Number:
541-382-5702

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
452 NE GREENWOOD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97701-4608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-382-5701
Provider Business Practice Location Address Fax Number:
541-382-5702
Provider Enumeration Date:
07/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CARMIENCKE
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
541-382-5701

Provider Taxonomy Codes

  • Taxonomy code: 152WV0400X , with the licence number:  OR1221AT , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 03256-5 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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