Provider Demographics
NPI:1962820050
Name:PVBLUFFTON
Entity Type:Organization
Organization Name:PVBLUFFTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-382-2542
Mailing Address - Street 1:3 MALPHRUS RD STE 101
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29910-6635
Mailing Address - Country:US
Mailing Address - Phone:843-837-9222
Mailing Address - Fax:
Practice Address - Street 1:3 MALPHRUS RD STE 101
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-6635
Practice Address - Country:US
Practice Address - Phone:843-837-9222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-04
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15029332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier