Provider Demographics
NPI:1104008416
Name:EYE SITE
Entity Type:Organization
Organization Name:EYE SITE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-586-0651
Mailing Address - Street 1:30 S MACDADE BLVD
Mailing Address - Street 2:
Mailing Address - City:GLENOLDEN
Mailing Address - State:PA
Mailing Address - Zip Code:19036-1725
Mailing Address - Country:US
Mailing Address - Phone:610-586-0651
Mailing Address - Fax:
Practice Address - Street 1:30 S MACDADE BLVD
Practice Address - Street 2:
Practice Address - City:GLENOLDEN
Practice Address - State:PA
Practice Address - Zip Code:19036-1725
Practice Address - Country:US
Practice Address - Phone:610-586-0651
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty