Provider Demographics
NPI:1407098908
Name:INDEPENDENCE CORPORATION
Entity Type:Organization
Organization Name:INDEPENDENCE CORPORATION
Other - Org Name:EYELAND OPTICAL INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INS AR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:PAUSINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-799-2020
Mailing Address - Street 1:4119 MAUCH CHUNK RD # C
Mailing Address - Street 2:
Mailing Address - City:COPLAY
Mailing Address - State:PA
Mailing Address - Zip Code:18037-2106
Mailing Address - Country:US
Mailing Address - Phone:610-799-2020
Mailing Address - Fax:610-799-4399
Practice Address - Street 1:3090 N SUSQUEHANNA TRAIL RD
Practice Address - Street 2:
Practice Address - City:SHAMOKIN DAM
Practice Address - State:PA
Practice Address - Zip Code:17876
Practice Address - Country:US
Practice Address - Phone:570-743-3937
Practice Address - Fax:570-743-3005
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INDEPENDENCE CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-03-30
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018518950002Medicaid
PA0018518950002Medicaid
PA0830100002Medicare NSC