Provider Demographics
NPI:1477757433
Name:BOURSE OPTICAL BOUTIQUE, INC.
Entity Type:Organization
Organization Name:BOURSE OPTICAL BOUTIQUE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:K
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:412-489-6726
Mailing Address - Street 1:2275 SWALLOW HILL RD
Mailing Address - Street 2:BUILDING 700
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15220-1656
Mailing Address - Country:US
Mailing Address - Phone:412-489-6726
Mailing Address - Fax:412-489-6732
Practice Address - Street 1:2275 SWALLOW HILL RD
Practice Address - Street 2:BUILDING 700
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15220-1656
Practice Address - Country:US
Practice Address - Phone:412-489-6726
Practice Address - Fax:412-489-6732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPAOEG001128152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA4328540001Medicare NSC
PA116316Medicare PIN