Provider Demographics
NPI:1558372821
Name:BELLEVUE OPTICAL INC.
Entity Type:Organization
Organization Name:BELLEVUE OPTICAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:O.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:W
Authorized Official - Last Name:GRANGE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:402-291-7144
Mailing Address - Street 1:1103 GALVIN RD S
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68005-3002
Mailing Address - Country:US
Mailing Address - Phone:402-291-7144
Mailing Address - Fax:402-292-7122
Practice Address - Street 1:1103 GALVIN RD S
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68005-3002
Practice Address - Country:US
Practice Address - Phone:402-291-7144
Practice Address - Fax:402-292-7122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========00Medicaid
NE0406380001Medicare ID - Type Unspecified