Provider Demographics
NPI:1144854670
Name:BRUCE R BEAN OD PLLC
Entity type:Organization
Organization Name:BRUCE R BEAN OD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-358-4814
Mailing Address - Street 1:347 W 110 S
Mailing Address - Street 2:
Mailing Address - City:LINDON
Mailing Address - State:UT
Mailing Address - Zip Code:84042-1724
Mailing Address - Country:US
Mailing Address - Phone:801-358-4814
Mailing Address - Fax:
Practice Address - Street 1:585 N STATE ST
Practice Address - Street 2:
Practice Address - City:LINDON
Practice Address - State:UT
Practice Address - Zip Code:84042-1339
Practice Address - Country:US
Practice Address - Phone:801-785-8512
Practice Address - Fax:801-785-8514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-24
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528515801001Medicaid