Provider Demographics
NPI:1891893483
Name:THE FISHIN' BUDDIES INC.
Entity Type:Organization
Organization Name:THE FISHIN' BUDDIES INC.
Other - Org Name:CRYSTAL VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:NOWIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-865-9900
Mailing Address - Street 1:3650 NAZARETH PIKE
Mailing Address - Street 2:BETHLEHEM VILLAGE SHOPPES
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18020-1115
Mailing Address - Country:US
Mailing Address - Phone:610-865-9900
Mailing Address - Fax:610-865-3446
Practice Address - Street 1:3650 NAZARETH PIKE
Practice Address - Street 2:BETHLEHEM VILLAGE SHOPPES
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18020-1115
Practice Address - Country:US
Practice Address - Phone:610-865-9900
Practice Address - Fax:610-865-3446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000927152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0070423700002OtherMA #
PA405869JKDMedicare ID - Type Unspecified
PAT30205Medicare UPIN