1366500183 NPI number — DR. RICHARD L BRILLIANT OPTOMETRY

Table of content: DR. RICHARD L BRILLIANT OPTOMETRY (NPI 1366500183)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366500183 NPI number — DR. RICHARD L BRILLIANT OPTOMETRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRILLIANT
Provider First Name:
RICHARD
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OPTOMETRY
Provider Gender Code:
M

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:
1366500183
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4 HIDDEN ACRES DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TABERNACLE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08088-8586
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:
215-276-1329

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 W SPROUL RD
Provider Second Line Business Practice Location Address:
SUITE 125
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19064-2033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-690-4900
Provider Business Practice Location Address Fax Number:
610-690-4910
Provider Enumeration Date:
12/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152WL0500X , with the licence number:  OEG000447 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: OEG000447 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 67097 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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