Provider Demographics
NPI:1104834266
Name:NORTH POCONO FAMILY EYECARE, LLC
Entity Type:Organization
Organization Name:NORTH POCONO FAMILY EYECARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:AGOSTINELLI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:570-842-0331
Mailing Address - Street 1:921 DRINKER TPKE
Mailing Address - Street 2:STE 15
Mailing Address - City:COVINGTON TWP
Mailing Address - State:PA
Mailing Address - Zip Code:18444-7947
Mailing Address - Country:US
Mailing Address - Phone:570-842-0331
Mailing Address - Fax:
Practice Address - Street 1:921 DRINKER TPKE
Practice Address - Street 2:STE 15
Practice Address - City:COVINGTON TWP
Practice Address - State:PA
Practice Address - Zip Code:18444-7947
Practice Address - Country:US
Practice Address - Phone:570-842-0331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG-000799152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA044425VWSMedicare ID - Type UnspecifiedGROUP PROVIDER NUMBER
PA5879980001Medicare NSC
PA105419VWSMedicare PIN
PAU83187Medicare UPIN