Provider Demographics
NPI:1427226281
Name:TOM GRUDIS OPTICAL CENTER
Entity Type:Organization
Organization Name:TOM GRUDIS OPTICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:KOONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-346-1771
Mailing Address - Street 1:428 SPRUCE STREET
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18503-1821
Mailing Address - Country:US
Mailing Address - Phone:570-346-1771
Mailing Address - Fax:570-346-5812
Practice Address - Street 1:428 SPRUCE STREET
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18503-1821
Practice Address - Country:US
Practice Address - Phone:570-346-1771
Practice Address - Fax:570-346-5812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-14
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA156FX1800X332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0498520001Medicare NSC