Provider Demographics
NPI:1164895611
Name:CUSSATT EYEWEAR
Entity Type:Organization
Organization Name:CUSSATT EYEWEAR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:CUSSATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-455-1100
Mailing Address - Street 1:601 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:WEST HAZLETON
Mailing Address - State:PA
Mailing Address - Zip Code:18202-1551
Mailing Address - Country:US
Mailing Address - Phone:570-455-1100
Mailing Address - Fax:
Practice Address - Street 1:601 N BROAD ST
Practice Address - Street 2:
Practice Address - City:WEST HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18202-1551
Practice Address - Country:US
Practice Address - Phone:570-455-1100
Practice Address - Fax:570-455-1101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
156F00000X
PA21950156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
No156F00000XEye and Vision Services ProvidersTechnician/TechnologistGroup - Multi-Specialty