Provider Demographics
NPI:1669646246
Name:SHIVERDECKER, ROBIN (LICENSED OPTICIAN)
Entity type:Individual
Prefix:MRS
First Name:ROBIN
Middle Name:
Last Name:SHIVERDECKER
Suffix:
Gender:F
Credentials:LICENSED OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45338-0658
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
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5728S156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician