1336299684 NPI number — BLADEN EYE CENTER, O.D., P.A.

Table of content: (NPI 1336299684)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336299684 NPI number — BLADEN EYE CENTER, O.D., P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLADEN EYE CENTER, O.D., P.A.
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:
1336299684
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/26/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2589
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELIZABETHTOWN
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28337-2589
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-862-4268
Provider Business Mailing Address Fax Number:
910-862-2057

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
409 EAST BROAD STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELIZABETHTOWN
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28337-2589
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-862-4268
Provider Business Practice Location Address Fax Number:
910-862-2057
Provider Enumeration Date:
01/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SCHMIDT
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OD
Authorized Official Telephone Number:
910-862-4268

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1447 , 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: 890152J , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0152J . This is a "BCBS NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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