Provider Demographics
NPI:1629113238
Name:457 OPTICAL, LLC
Entity Type:Organization
Organization Name:457 OPTICAL, LLC
Other - Org Name:457 OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOANN
Authorized Official - Middle Name:B
Authorized Official - Last Name:STRAIN
Authorized Official - Suffix:
Authorized Official - Credentials:O D
Authorized Official - Phone:412-257-0155
Mailing Address - Street 1:457 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15017-2370
Mailing Address - Country:US
Mailing Address - Phone:412-257-0155
Mailing Address - Fax:412-220-8643
Practice Address - Street 1:457 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEVILLE
Practice Address - State:PA
Practice Address - Zip Code:15017-2370
Practice Address - Country:US
Practice Address - Phone:412-257-0155
Practice Address - Fax:412-220-8643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001618825OtherCLARITY VISION
PAA08009796OtherDMERC-A NSC
PA5126600001Medicare NSC