1639125214 NPI number — BEN DOMIANO OPTICAL INCORPORATED

Table of content: (NPI 1639125214)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639125214 NPI number — BEN DOMIANO OPTICAL INCORPORATED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEN DOMIANO OPTICAL INCORPORATED
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:
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:
1639125214
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
817 S MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLD FORGE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18518-1431
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-457-2020
Provider Business Mailing Address Fax Number:
570-457-2787

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
817 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OLD FORGE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18518-1431
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-457-2020
Provider Business Practice Location Address Fax Number:
570-457-2787
Provider Enumeration Date:
05/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DOMIANO
Authorized Official First Name:
BENJAMIN
Authorized Official Middle Name:
G
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
570-457-2020

Provider Taxonomy Codes

  • Taxonomy code: 156FX1800X , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PA817 . This is a "VISION BENEFITS OF AMERIC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 48926 . This is a "GEISINGER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 15932 . This is a "SPECTARA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 9911 . This is a "DAVIS VISION" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: DO0001565000 . This is a "HIGHMARK" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: BE282600 . This is a "CLARITY VISION" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: PA0685 . This is a "EYEMED/COLE VISION" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 393342 . This is a "NVA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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