Provider Demographics
NPI:1902379936
Name:EVERETT EYE CARE CENTER, LLC
Entity Type:Organization
Organization Name:EVERETT EYE CARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:SUZANNE
Authorized Official - Last Name:STONE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:814-652-6221
Mailing Address - Street 1:141 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:PA
Mailing Address - Zip Code:15537-1259
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:141 E MAIN ST
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:PA
Practice Address - Zip Code:15537-1259
Practice Address - Country:US
Practice Address - Phone:814-652-6221
Practice Address - Fax:814-652-9143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-02
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103377027001Medicaid