Provider Demographics
NPI:1891828794
Name:MD BARTLEY OPTICIANS
Entity Type:Organization
Organization Name:MD BARTLEY OPTICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DON
Authorized Official - Last Name:BARTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-692-7619
Mailing Address - Street 1:2311 YORKSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006-2446
Mailing Address - Country:US
Mailing Address - Phone:605-692-7619
Mailing Address - Fax:605-697-9005
Practice Address - Street 1:2311 YORKSHIRE DR
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-2446
Practice Address - Country:US
Practice Address - Phone:605-692-7619
Practice Address - Fax:605-697-9005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD9280210332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9290210Medicaid
SD9290210Medicaid