Basic Information
| Provider Information | |||||||||
| NPI: | 1972549657 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INDEPENDENCE CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EYELAND OPTICAL INC. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 2274 MACARTHUR RD | ||||||||
| Address2: | |||||||||
| City: | WHITEHALL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180524522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104323937 | ||||||||
| FaxNumber: | 6104320124 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 09/28/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PAUSINGER | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | INSURANCE ADMIN | ||||||||
| AuthorizedOfficialTelephone: | 6107992020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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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 |