Provider Demographics
NPI:1366627275
Name:BOARDMAN FAMILY EYE CARE PC
Entity Type:Organization
Organization Name:BOARDMAN FAMILY EYE CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AVERY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOARDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:570-265-3668
Mailing Address - Street 1:889 CRAFTMASTER ROAD
Mailing Address - Street 2:PO BOX 331
Mailing Address - City:WYSOX
Mailing Address - State:PA
Mailing Address - Zip Code:18854-0000
Mailing Address - Country:US
Mailing Address - Phone:570-265-3668
Mailing Address - Fax:570-265-8936
Practice Address - Street 1:889 CRAFTMASTER ROAD
Practice Address - Street 2:
Practice Address - City:WYSOX
Practice Address - State:PA
Practice Address - Zip Code:18854-0000
Practice Address - Country:US
Practice Address - Phone:570-265-3668
Practice Address - Fax:570-265-8936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000896152W00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADR8207OtherMEDICARE RAILROAD
PAU24495Medicare UPIN
PA6574680001Medicare NSC
PA217628Medicare PIN