Provider Demographics
NPI:1639321821
Name:DR. BLOOMBERG'S EYE CLINIC
Entity Type:Organization
Organization Name:DR. BLOOMBERG'S EYE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:VEGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-758-6671
Mailing Address - Street 1:2200 NILES CORTLAND RD SE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-3042
Mailing Address - Country:US
Mailing Address - Phone:330-372-6676
Mailing Address - Fax:330-372-9206
Practice Address - Street 1:2200 NILES CORTLAND RD SE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-3042
Practice Address - Country:US
Practice Address - Phone:330-372-6676
Practice Address - Fax:330-372-9206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4008/T-032152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0770929Medicaid