Provider Demographics
NPI:1942746342
Name:BRUCE LUNDIN OD LLC
Entity Type:Organization
Organization Name:BRUCE LUNDIN OD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:L
Authorized Official - Last Name:LUNDIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:435-753-3906
Mailing Address - Street 1:1550 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-1918
Mailing Address - Country:US
Mailing Address - Phone:435-753-3906
Mailing Address - Fax:
Practice Address - Street 1:1550 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-1918
Practice Address - Country:US
Practice Address - Phone:435-753-3906
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-10
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT279166-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty