Provider Demographics
NPI:1841493897
Name:CRANBERRY EYECARE LLC
Entity type:Organization
Organization Name:CRANBERRY EYECARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ELMER
Authorized Official - Middle Name:W
Authorized Official - Last Name:EBECK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:724-776-5888
Mailing Address - Street 1:101 SMITH DR STE 3
Mailing Address - Street 2:
Mailing Address - City:CRANBERRY TWP
Mailing Address - State:PA
Mailing Address - Zip Code:16066-4129
Mailing Address - Country:US
Mailing Address - Phone:724-776-5888
Mailing Address - Fax:724-935-2900
Practice Address - Street 1:101 SMITH DR STE 3
Practice Address - Street 2:
Practice Address - City:CRANBERRY TWP
Practice Address - State:PA
Practice Address - Zip Code:16066-4129
Practice Address - Country:US
Practice Address - Phone:724-776-5888
Practice Address - Fax:724-935-2900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002021152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102497110Medicaid
PA5717200001Medicare NSC