Healthcare Provider Details

I. General information

NPI: 1568493351
Provider Name (Legal Business Name): BOUQUET MULLIGAN DEMAIO EYE PROFESSIONALS P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 07/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 W PENN AVE
CLEONA PA
17042-3230
US

IV. Provider business mailing address

233 W PENN AVE
CLEONA PA
17042-3230
US

V. Phone/Fax

Practice location:
  • Phone: 717-272-0581
  • Fax: 717-274-5889
Mailing address:
  • Phone: 717-272-0581
  • Fax: 717-274-5889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG000036
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. GREGORY M BRACALE
Title or Position: ADMININSTRATOR
Credential:
Phone: 717-272-0581