1912174038 NPI number — LORI J. BENDE, O.D., PROFESSIONAL OPTOMETRIC CORPORATION

Table of content: (NPI 1912174038)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912174038 NPI number — LORI J. BENDE, O.D., PROFESSIONAL OPTOMETRIC CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LORI J. BENDE, O.D., PROFESSIONAL OPTOMETRIC CORPORATION
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:
1912174038
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4009 GOVERNOR DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92122-2522
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-453-0444
Provider Business Mailing Address Fax Number:
858-453-0471

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4009 GOVERNOR DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92122-2522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-453-0444
Provider Business Practice Location Address Fax Number:
858-453-0471
Provider Enumeration Date:
05/08/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BENDE
Authorized Official First Name:
LORI
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OPTOMETRIST
Authorized Official Telephone Number:
858-453-0444

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  10611T , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1264740001 . This is a "DMERC PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: W18234 . This is a "MEDICARE PROVIDER NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: OP10611 . This is a "NHIC ID" identifier . This identifiers is of the category "OTHER".




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