Provider Demographics
NPI:1649269374
Name:LOWER BURRELL FASHION OPTICAL, INC.
Entity type:Organization
Organization Name:LOWER BURRELL FASHION OPTICAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:DARCY
Authorized Official - Middle Name:
Authorized Official - Last Name:CALIGURI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-339-4595
Mailing Address - Street 1:245 HILLCREST PLZ
Mailing Address - Street 2:
Mailing Address - City:LOWER BURRELL
Mailing Address - State:PA
Mailing Address - Zip Code:15068-3506
Mailing Address - Country:US
Mailing Address - Phone:724-339-4595
Mailing Address - Fax:724-339-0257
Practice Address - Street 1:245 HILLCREST PLZ
Practice Address - Street 2:
Practice Address - City:LOWER BURRELL
Practice Address - State:PA
Practice Address - Zip Code:15068-3506
Practice Address - Country:US
Practice Address - Phone:724-339-4595
Practice Address - Fax:724-339-0257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-15
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001916152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA07647057Medicaid
PA031712Medicare ID - Type Unspecified
PA07647057Medicaid