Provider Demographics
NPI:1780011999
Name:BOUQUET MULLIGAN EYE PROFESSIONALS LTD
Entity Type:Organization
Organization Name:BOUQUET MULLIGAN EYE PROFESSIONALS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:M
Authorized Official - Last Name:BRACALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-272-0581
Mailing Address - Street 1:233 W PENN AVE
Mailing Address - Street 2:
Mailing Address - City:CLEONA
Mailing Address - State:PA
Mailing Address - Zip Code:17042-3230
Mailing Address - Country:US
Mailing Address - Phone:717-272-0581
Mailing Address - Fax:717-274-5889
Practice Address - Street 1:600 FREE MASON DRIVE
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:PA
Practice Address - Zip Code:17022
Practice Address - Country:US
Practice Address - Phone:717-272-0581
Practice Address - Fax:717-274-5889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA4367030002OtherPTAN