Provider Demographics
NPI:1912035098
Name:HENDRICKS & SIDEBOTTOM OPTICIANS
Entity Type:Organization
Organization Name:HENDRICKS & SIDEBOTTOM OPTICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:LAURENCE
Authorized Official - Last Name:SIDEBOTTOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-644-2020
Mailing Address - Street 1:500 CHESTERBROOK BLVD
Mailing Address - Street 2:STE C5A
Mailing Address - City:WAYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19087-5608
Mailing Address - Country:US
Mailing Address - Phone:610-644-2020
Mailing Address - Fax:
Practice Address - Street 1:500 CHESTERBROOK BLVD
Practice Address - Street 2:STE C5A
Practice Address - City:WAYNE
Practice Address - State:PA
Practice Address - Zip Code:19087-5608
Practice Address - Country:US
Practice Address - Phone:610-644-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2009-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0382590002Medicare NSC