Provider Demographics
NPI:1972838340
Name:LEWISBURG OPTICAL
Entity Type:Organization
Organization Name:LEWISBURG OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED OPTICIAN/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIVERDECKER
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:937-962-4444
Mailing Address - Street 1:210 N COMMERCE ST
Mailing Address - Street 2:PO BOX 658
Mailing Address - City:LEWISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45338-9343
Mailing Address - Country:US
Mailing Address - Phone:937-962-4444
Mailing Address - Fax:937-962-4443
Practice Address - Street 1:210 N COMMERCE ST
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:OH
Practice Address - Zip Code:45338-9343
Practice Address - Country:US
Practice Address - Phone:937-962-4444
Practice Address - Fax:937-962-4443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-02
Last Update Date:2009-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5728S332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier