Provider Demographics
NPI:1407898026
Name:BAY OPTICAL LABORATORY CORP.
Entity Type:Organization
Organization Name:BAY OPTICAL LABORATORY CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT MANAGER/BOOKKEEPER
Authorized Official - Prefix:
Authorized Official - First Name:LILY
Authorized Official - Middle Name:M
Authorized Official - Last Name:VAN ELSBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-756-2571
Mailing Address - Street 1:3587 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:NORTH BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97459-1251
Mailing Address - Country:US
Mailing Address - Phone:541-756-2571
Mailing Address - Fax:541-756-3976
Practice Address - Street 1:3587 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:NORTH BEND
Practice Address - State:OR
Practice Address - Zip Code:97459-1251
Practice Address - Country:US
Practice Address - Phone:541-756-2571
Practice Address - Fax:541-756-3976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR012641Medicaid
OR0009759000OtherPROVIDER NUMBER
OR0009759000OtherPROVIDER NUMBER