Basic Information
| Provider Information | |||||||||
| NPI: | 1952543720 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INDEPENDENCE CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | EYELAND OPTICAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4119 MAUCH CHUNK RD # C | ||||||||
| Address2: | |||||||||
| City: | COPLAY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180372106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6107992020 | ||||||||
| FaxNumber: | 6107994399 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 W FRONT ST | ||||||||
| Address2: | |||||||||
| City: | BERWICK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 186034211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5707592325 | ||||||||
| FaxNumber: | 5707593101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2009 | ||||||||
| LastUpdateDate: | 03/06/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PAUSINGER | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | INS AR | ||||||||
| AuthorizedOfficialTelephone: | 6107992020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | INDEPENDENCE CORPORATION | ||||||||
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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 |