1003241274 NPI number — OPTICAL NEI INC.

Table of content: (NPI 1003241274)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003241274 NPI number — OPTICAL NEI INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTICAL NEI INC.
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:
1003241274
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 MIFFLIN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCRANTON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18503-1982
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-342-3145
Provider Business Mailing Address Fax Number:
570-344-1309

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
RT. 940, POCONO SUMMIT PLAZA
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POCONO SUMMIT
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18346
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-839-7973
Provider Business Practice Location Address Fax Number:
570-839-7975
Provider Enumeration Date:
09/06/2013

Additional Information

Authorized Official

Authorized Official Last Name:
JORDAN
Authorized Official First Name:
ARTHUR
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER, BOARD OF DIRECTORS
Authorized Official Telephone Number:
570-342-3145

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  6000007290 , 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: 773550014 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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