Basic Information
Provider Information | |||||||||
NPI: | 1508008376 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | INDEPENDENCE CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | EYELAND OPTICAL INC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4119 MAUCH CHUNK RD # C | ||||||||
Address2: |   | ||||||||
City: | COPLAY | ||||||||
State: | PA | ||||||||
PostalCode: | 180372106 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6107992020 | ||||||||
FaxNumber: | 6107994399 | ||||||||
Practice Location | |||||||||
Address1: | 578 SUSQUEHANNA BLVD | ||||||||
Address2: |   | ||||||||
City: | HAZLE TOWNSHIP | ||||||||
State: | PA | ||||||||
PostalCode: | 182023233 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5704592200 | ||||||||
FaxNumber: | 5704598690 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/25/2009 | ||||||||
LastUpdateDate: | 12/06/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PAUSINGER | ||||||||
AuthorizedOfficialFirstName: | LISA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | INS AR | ||||||||
AuthorizedOfficialTelephone: | 6107992020 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | INDEPENDENCE CORPORATION | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 0018518950002 | 05 | PA |   | MEDICAID |