Healthcare Provider Details

I. General information

NPI: 1962906537
Provider Name (Legal Business Name): BRADLEY J BLUMENSTOCK OD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2018
Last Update Date: 03/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 PINE LAKE RD STE 1
LINCOLN NE
68512-3692
US

IV. Provider business mailing address

1501 PINE LAKE RD STE 1
LINCOLN NE
68512-3692
US

V. Phone/Fax

Practice location:
  • Phone: 402-421-7773
  • Fax: 402-421-7859
Mailing address:
  • Phone: 402-421-7773
  • Fax: 402-421-7859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number1106
License Number StateNE

VIII. Authorized Official

Name: DR. BRADLEY J BLUMENSTOCK
Title or Position: OPTOMETRIST
Credential: OD, PC
Phone: 402-421-7773