Healthcare Provider Details

I. General information

NPI: 1114478708
Provider Name (Legal Business Name): BESPOKE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2016
Last Update Date: 01/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 POTRERO AVE
SAN FRANCISCO CA
94103-4814
US

IV. Provider business mailing address

255 POTRERO AVE
SAN FRANCISCO CA
94103-4814
US

V. Phone/Fax

Practice location:
  • Phone: 617-851-5957
  • Fax:
Mailing address:
  • Phone: 617-851-5957
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT VARADY
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 617-851-5957