Provider Demographics
NPI:1184899783
Name:JEANETTE L. BERGSTROM DBA BURNT HILLS OPTICAL
Entity type:Organization
Organization Name:JEANETTE L. BERGSTROM DBA BURNT HILLS OPTICAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEANETTE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BERGSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-399-6130
Mailing Address - Street 1:PO BOX 209
Mailing Address - Street 2:793 ROUTE 50
Mailing Address - City:BURNT HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:12027-0209
Mailing Address - Country:US
Mailing Address - Phone:518-399-6130
Mailing Address - Fax:518-399-4604
Practice Address - Street 1:793 STATE ROUTE 50
Practice Address - Street 2:
Practice Address - City:BURNT HILLS
Practice Address - State:NY
Practice Address - Zip Code:12027-9501
Practice Address - Country:US
Practice Address - Phone:518-399-6130
Practice Address - Fax:518-399-4604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-24
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0338420001Medicare NSC