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General NPI Number Information
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NPI Number | 1891469698
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Entity Type | Organization
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Legal Business Name | BSGI HOLDINGS LLC
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Dates
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Enumeration Date | 08/04/2021
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Last Update Date | 08/04/2021
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Provider Practice Location Address
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Address Line | 2102 N PROSPECT AVE
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City | CHAMPAIGN
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State | IL
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Zip | 61822-1231
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Country | US
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Telephone | 217-352-2468
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Fax |
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Provider Business Mailing Address
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Address Line | 1090 BUCKS POND RD
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City | MONTICELLO
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State | IL
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Zip | 61856-8058
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | DR. BRADLEY GRANT
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Credential | OD
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Telephone | 901-496-9129
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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 |
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License Number State |
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