1609364058 NPI number — EYETIQUE CORPORATION

Table of content: (NPI 1609364058)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609364058 NPI number — EYETIQUE CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYETIQUE CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609364058
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/27/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
211 E BROADWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62002-6220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-462-9818
Provider Business Mailing Address Fax Number:
314-741-4947

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
535 ADAMS SHOPPES
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARS
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16046-3968
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-591-8515
Provider Business Practice Location Address Fax Number:
724-591-8517
Provider Enumeration Date:
05/01/2018

Additional Information

Authorized Official

Authorized Official Last Name:
SHORT
Authorized Official First Name:
CATHY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CREDENTIALING MANAGER
Authorized Official Telephone Number:
618-462-9818

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PENDING , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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