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General NPI Number Information
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NPI Number | 1477757433
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Entity Type | Organization
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Legal Business Name | BOURSE OPTICAL BOUTIQUE, INC.
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Dates
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Enumeration Date | 06/13/2007
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Last Update Date | 03/04/2014
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Provider Practice Location Address
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Address Line | 2275 SWALLOW HILL RD BUILDING 700
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City | PITTSBURGH
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State | PA
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Zip | 15220-1656
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Country | US
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Telephone | 412-489-6726
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Fax | 412-489-6732
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Provider Business Mailing Address
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Address Line | 2275 SWALLOW HILL RD BUILDING 700
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City | PITTSBURGH
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State | PA
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Zip | 15220-1656
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Country | US
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Telephone | 412-489-6726
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Fax | 412-489-6732
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JOHN K. GREGORY
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Credential | O.D.
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Telephone | 412-489-6726
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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 | PAOEG001128
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License Number State | PA
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