Provider Demographics
NPI:1871048405
Name:PBW OPTOMETRY PC
Entity type:Organization
Organization Name:PBW OPTOMETRY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DOONE
Authorized Official - Middle Name:
Authorized Official - Last Name:BURGENER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-505-5843
Mailing Address - Street 1:1923 MCCULLOCH BLVD #102
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-6722
Mailing Address - Country:US
Mailing Address - Phone:928-854-3555
Mailing Address - Fax:928-854-4544
Practice Address - Street 1:1923 MCCULLOCH BLVD #102
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6722
Practice Address - Country:US
Practice Address - Phone:928-854-3555
Practice Address - Fax:928-854-4544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-24
Last Update Date:2017-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1060332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
7547290001OtherMEDICARE NSC
AZU78025Medicare UPIN
AZ7547290001Medicare NSC
AZZ114460Medicare PIN