Provider Demographics
NPI:1013085539
Name:CLASSIC EYEWARE
Entity type:Organization
Organization Name:CLASSIC EYEWARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDANELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-376-9173
Mailing Address - Street 1:PO BOX 870450
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99687-0450
Mailing Address - Country:US
Mailing Address - Phone:907-376-9173
Mailing Address - Fax:907-376-8180
Practice Address - Street 1:935 E WESTPOINT DR
Practice Address - Street 2:STE 207
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654
Practice Address - Country:US
Practice Address - Phone:907-376-9173
Practice Address - Fax:907-376-8180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK172156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKOD0090Medicaid
AKOD0090Medicaid
AKT67001Medicare UPIN