1477801876 NPI number — BRIERDALE OPTOMETRY PA

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 1477801876 NPI number — BRIERDALE OPTOMETRY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIERDALE OPTOMETRY PA
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:
6
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:
1477801876
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/14/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3214 CHARLES B ROOT WYND
Provider Second Line Business Mailing Address:
SUITE 155
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27612-5440
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-881-0900
Provider Business Mailing Address Fax Number:
919-341-5273

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10371 MONCREIFFE RD
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27617-7817
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-341-4435
Provider Business Practice Location Address Fax Number:
919-341-5273
Provider Enumeration Date:
08/16/2012

Additional Information

Authorized Official

Authorized Official Last Name:
SAID
Authorized Official First Name:
OSAMA
Authorized Official Middle Name:
H
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
919-881-0900

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1776 , 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)

  • Identifier: 026Y1 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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