Provider Demographics
NPI:1457597882
Name:BORDEAUX OPTICAL, INC.
Entity Type:Organization
Organization Name:BORDEAUX OPTICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN/MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:FINDLAY
Authorized Official - Last Name:BOWDEN
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:910-485-4114
Mailing Address - Street 1:3363 VILLAGE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-4508
Mailing Address - Country:US
Mailing Address - Phone:910-485-4114
Mailing Address - Fax:910-485-4116
Practice Address - Street 1:3363 VILLAGE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4508
Practice Address - Country:US
Practice Address - Phone:910-485-4114
Practice Address - Fax:910-485-4116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-07
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1092335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC42987400001Medicare PIN