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General NPI Number Information
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NPI Number | 1043573470
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Entity Type | Organization
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Legal Business Name | BLAKE BUSH FAMILY EYECARE INC.
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Dates
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Enumeration Date | 06/20/2012
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Last Update Date | 02/06/2015
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Provider Practice Location Address
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Address Line | 908 N ROCKFORD RD SUITE E
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City | ARDMORE
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State | OK
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Zip | 73401-2540
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Country | US
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Telephone | 580-223-7333
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Fax |
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Provider Business Mailing Address
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Address Line | 908 N ROCKFORD RD SUITE E
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City | ARDMORE
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State | OK
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Zip | 73401-2540
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Country | US
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Telephone | 580-223-7333
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. BLAKE ROBERT BUSH
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Credential | O.D.
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Telephone | 580-223-7333
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2550
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License Number State | OK
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