Provider Demographics
NPI:1912147869
Name:BURTON C BLAUROCK OD
Entity Type:Organization
Organization Name:BURTON C BLAUROCK OD
Other - Org Name:ELEGANT EYE OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BURTON
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:BLAUROCK
Authorized Official - Suffix:
Authorized Official - Credentials:OPTOMETRIST
Authorized Official - Phone:760-340-4524
Mailing Address - Street 1:42390 BOB HOPE DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-4469
Mailing Address - Country:US
Mailing Address - Phone:760-340-4524
Mailing Address - Fax:760-340-4796
Practice Address - Street 1:42390 BOB HOPE DR
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-4469
Practice Address - Country:US
Practice Address - Phone:760-340-4524
Practice Address - Fax:760-340-4796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-04
Last Update Date:2009-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5996T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4190770001Medicare NSC