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
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
152W00000X5376TGTXY193400000X SINGLE SPECIALTY GROUPEye and Vision Services ProvidersOptometrist 

ID Information
IDTypeStateIssuerDescription
8L456401TXINDIVIDUAL PTANOTHER


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