Provider Demographics
NPI:1841227378
Name:BURLINGTON OPTICIANS, INC.
Entity type:Organization
Organization Name:BURLINGTON OPTICIANS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DARA
Authorized Official - Middle Name:J
Authorized Official - Last Name:HENNEKE
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:319-753-0437
Mailing Address - Street 1:580 S ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52601-1666
Mailing Address - Country:US
Mailing Address - Phone:319-753-0437
Mailing Address - Fax:319-752-8751
Practice Address - Street 1:580 S ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52601-1666
Practice Address - Country:US
Practice Address - Phone:319-753-0437
Practice Address - Fax:319-752-8751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NOT REQUIRED332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0546970001Medicare ID - Type UnspecifiedMEDICARE PROVIDER #