Provider Demographics
NPI:1124365648
Name:DALE H. BRICKER, O.D., P.C.
Entity Type:Organization
Organization Name:DALE H. BRICKER, O.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:H
Authorized Official - Last Name:BRICKER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:541-980-8925
Mailing Address - Street 1:301 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-2107
Mailing Address - Country:US
Mailing Address - Phone:541-296-5878
Mailing Address - Fax:541-296-3434
Practice Address - Street 1:301 E 2ND ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-2107
Practice Address - Country:US
Practice Address - Phone:541-296-5878
Practice Address - Fax:541-296-3434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-04
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2657ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
R115820Medicare UPIN