1457597882 NPI number — BORDEAUX OPTICAL, INC.

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 1457597882 NPI number — BORDEAUX OPTICAL, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BORDEAUX OPTICAL, INC.
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:
1457597882
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/07/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3363 VILLAGE DR
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28304-4508
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-485-4114
Provider Business Mailing Address Fax Number:
910-485-4116

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3363 VILLAGE DR
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28304-4508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-485-4114
Provider Business Practice Location Address Fax Number:
910-485-4116
Provider Enumeration Date:
01/07/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BOWDEN
Authorized Official First Name:
JEAN
Authorized Official Middle Name:
FINDLAY
Authorized Official Title or Position:
OPTICIAN/MANAGER
Authorized Official Telephone Number:
910-485-4114

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X , with the licence number:  1092 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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