Provider Demographics
NPI:1356526370
Name:THE EYEGLASS SHOPPE, INC.
Entity type:Organization
Organization Name:THE EYEGLASS SHOPPE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWNFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:724-539-1900
Mailing Address - Street 1:3887 ROUTE 30
Mailing Address - Street 2:
Mailing Address - City:LATROBE
Mailing Address - State:PA
Mailing Address - Zip Code:15650-5256
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3887 ROUTE 30
Practice Address - Street 2:
Practice Address - City:LATROBE
Practice Address - State:PA
Practice Address - Zip Code:15650-5256
Practice Address - Country:US
Practice Address - Phone:724-539-1900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001664152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1023915400001Medicaid
PAV06727Medicare UPIN
PA1023915400001Medicaid
PADR3550Medicare PIN