Provider Demographics
NPI:1962906537
Name:BRADLEY J BLUMENSTOCK OD, PC
Entity type:Organization
Organization Name:BRADLEY J BLUMENSTOCK OD, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BLUMENSTOCK
Authorized Official - Suffix:
Authorized Official - Credentials:OD, PC
Authorized Official - Phone:402-421-7773
Mailing Address - Street 1:1501 PINE LAKE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68512-3692
Mailing Address - Country:US
Mailing Address - Phone:402-421-7773
Mailing Address - Fax:402-421-7859
Practice Address - Street 1:1501 PINE LAKE RD STE 1
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68512-3692
Practice Address - Country:US
Practice Address - Phone:402-421-7773
Practice Address - Fax:402-421-7859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-20
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1106261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026719300Medicaid