Provider Demographics
NPI:1801960919
Name:BLUEBONNET VISION
Entity type:Organization
Organization Name:BLUEBONNET VISION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:
Authorized Official - Last Name:DIBENEDETTO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:225-291-2414
Mailing Address - Street 1:4451 BLUEBONNET BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-9639
Mailing Address - Country:US
Mailing Address - Phone:225-291-2414
Mailing Address - Fax:225-291-2418
Practice Address - Street 1:4451 BLUEBONNET BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-9639
Practice Address - Country:US
Practice Address - Phone:225-291-2414
Practice Address - Fax:225-291-2418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1013949833OtherNPI
LA1255360525OtherNPI