Provider Demographics
NPI:1952571895
Name:LARRY-W-BLOOMINGBURG-OD
Entity Type:Organization
Organization Name:LARRY-W-BLOOMINGBURG-OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:W
Authorized Official - Last Name:BLLOMINGBURG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:731-989-3511
Mailing Address - Street 1:138 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:TN
Mailing Address - Zip Code:38340-2323
Mailing Address - Country:US
Mailing Address - Phone:731-989-3511
Mailing Address - Fax:731-989-3515
Practice Address - Street 1:138 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:TN
Practice Address - Zip Code:38340-2323
Practice Address - Country:US
Practice Address - Phone:731-989-3511
Practice Address - Fax:731-989-3515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-06
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN573332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0123960001Medicare NSC