Provider Demographics
NPI:1003961723
Name:ICU2INC
Entity Type:Organization
Organization Name:ICU2INC
Other - Org Name:CLEAR IMAGE OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTICIAN/TECH
Authorized Official - Prefix:MS
Authorized Official - First Name:GINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:TANANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-876-5200
Mailing Address - Street 1:RTE 6 TRAP PLAZA
Mailing Address - Street 2:
Mailing Address - City:EYNON
Mailing Address - State:PA
Mailing Address - Zip Code:18403
Mailing Address - Country:US
Mailing Address - Phone:570-876-5200
Mailing Address - Fax:570-876-5612
Practice Address - Street 1:RTE 6 TRAP PLAZA
Practice Address - Street 2:
Practice Address - City:EYNON
Practice Address - State:PA
Practice Address - Zip Code:18403
Practice Address - Country:US
Practice Address - Phone:570-876-5200
Practice Address - Fax:570-876-5612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA123944OtherMEDICARE (PTAN)