1184899783 NPI number — JEANETTE L. BERGSTROM DBA BURNT HILLS OPTICAL

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184899783 NPI number — JEANETTE L. BERGSTROM DBA BURNT HILLS OPTICAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEANETTE L. BERGSTROM DBA BURNT HILLS OPTICAL
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:
BURNT HILLS OPTICAL
Provider Other Organization Name Type Code:
3
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:
1184899783
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 209
Provider Second Line Business Mailing Address:
793 ROUTE 50
Provider Business Mailing Address City Name:
BURNT HILLS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12027-0209
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-399-6130
Provider Business Mailing Address Fax Number:
518-399-4604

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
793 STATE ROUTE 50
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURNT HILLS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12027-9501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-399-6130
Provider Business Practice Location Address Fax Number:
518-399-4604
Provider Enumeration Date:
04/24/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BERGSTROM
Authorized Official First Name:
JEANETTE
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
518-399-6130

Provider Taxonomy Codes

  • Taxonomy code: 156FX1800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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