1962906537 NPI number — BRADLEY J BLUMENSTOCK OD, PC

Table of content: (NPI 1962906537)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962906537 NPI number — BRADLEY J BLUMENSTOCK OD, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRADLEY J BLUMENSTOCK OD, PC
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:
1962906537
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/28/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1501 PINE LAKE RD STE 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LINCOLN
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68512-3692
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-421-7773
Provider Business Mailing Address Fax Number:
402-421-7859

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1501 PINE LAKE RD STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LINCOLN
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68512-3692
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-421-7773
Provider Business Practice Location Address Fax Number:
402-421-7859
Provider Enumeration Date:
03/20/2018

Additional Information

Authorized Official

Authorized Official Last Name:
BLUMENSTOCK
Authorized Official First Name:
BRADLEY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OPTOMETRIST
Authorized Official Telephone Number:
402-421-7773

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X , with the licence number:  1106 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10026719300 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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