1366627275 NPI number — BOARDMAN FAMILY EYE CARE PC

Table of content: (NPI 1366627275)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366627275 NPI number — BOARDMAN FAMILY EYE CARE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOARDMAN FAMILY EYE CARE PC
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:
1366627275
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/24/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
889 CRAFTMASTER ROAD
Provider Second Line Business Mailing Address:
PO BOX 331
Provider Business Mailing Address City Name:
WYSOX
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18854-0000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-265-3668
Provider Business Mailing Address Fax Number:
570-265-8936

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
889 CRAFTMASTER ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WYSOX
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18854-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-265-3668
Provider Business Practice Location Address Fax Number:
570-265-8936
Provider Enumeration Date:
01/09/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BOARDMAN
Authorized Official First Name:
AVERY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
570-265-3668

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OEG000896 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X , with the licence number: OEG000896 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DR8207 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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