Basic Information
Provider Information | |||||||||
NPI: | 1841223831 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BEDFORD EYECARE, P.A. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FIRST EYE CARE BEDFORD | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2400 AIRPORT FWY STE 140 | ||||||||
Address2: |   | ||||||||
City: | BEDFORD | ||||||||
State: | TX | ||||||||
PostalCode: | 760226098 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9729602020 | ||||||||
FaxNumber: | 9729602063 | ||||||||
Practice Location | |||||||||
Address1: | 2400 AIRPORT FWY STE 140 | ||||||||
Address2: |   | ||||||||
City: | BEDFORD | ||||||||
State: | TX | ||||||||
PostalCode: | 760226098 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8172842964 | ||||||||
FaxNumber: | 8172832760 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/10/2006 | ||||||||
LastUpdateDate: | 06/21/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BOURQUE | ||||||||
AuthorizedOfficialFirstName: | LORI | ||||||||
AuthorizedOfficialMiddleName: | MARIE | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 9729602020 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | O.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 5376TG | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 8L4564 | 01 | TX | INDIVIDUAL PTAN | OTHER |