Basic Information
| Provider Information | |||||||||
| NPI: | 1083894588 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALLEGANY OPTICAL LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ALLEGANY OPTICAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 626 CHAMBERSBURG MALL | ||||||||
| Address2: | |||||||||
| City: | CHAMBERSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 172028101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172637050 | ||||||||
| FaxNumber: | 7172633277 | ||||||||
| Practice Location | |||||||||
| Address1: | 626 CHAMBERSBURG MALL | ||||||||
| Address2: | |||||||||
| City: | CHAMBERSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 172028101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172637050 | ||||||||
| FaxNumber: | 7172633277 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2007 | ||||||||
| LastUpdateDate: | 11/13/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WHITELOCK | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | O.D. / MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 7172632389 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | O.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 6000003977 | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1007510100010 | 05 | PA | MEDICAID | CJ5439 | 01 | PA | RAILROAD MEDICARE | OTHER | 1007510100006 | 05 | PA | MEDICAID |