Provider Demographics
NPI:1629298211
Name:LAWNDALE OPTOMETRY ASSOCIATES PA
Entity Type:Organization
Organization Name:LAWNDALE OPTOMETRY ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:REBECK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:336-275-1254
Mailing Address - Street 1:2154-A LAWNDALE DRIVE
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-7102
Mailing Address - Country:US
Mailing Address - Phone:336-275-1254
Mailing Address - Fax:
Practice Address - Street 1:2154-A LAWNDALE DRIVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-7102
Practice Address - Country:US
Practice Address - Phone:336-275-1254
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2466897Medicare ID - Type Unspecified