1477757433 NPI number — BOURSE OPTICAL BOUTIQUE, 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 1477757433 NPI number — BOURSE OPTICAL BOUTIQUE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOURSE OPTICAL BOUTIQUE, 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:
1477757433
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/04/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2275 SWALLOW HILL RD
Provider Second Line Business Mailing Address:
BUILDING 700
Provider Business Mailing Address City Name:
PITTSBURGH
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15220-1656
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
412-489-6726
Provider Business Mailing Address Fax Number:
412-489-6732

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2275 SWALLOW HILL RD
Provider Second Line Business Practice Location Address:
BUILDING 700
Provider Business Practice Location Address City Name:
PITTSBURGH
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15220-1656
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
412-489-6726
Provider Business Practice Location Address Fax Number:
412-489-6732
Provider Enumeration Date:
06/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GREGORY
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
K.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
412-489-6726

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  PAOEG001128 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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