Provider Demographics
NPI:1982732715
Name:CUSTOM EYES RX INC
Entity Type:Organization
Organization Name:CUSTOM EYES RX INC
Other - Org Name:FASHION LENS LAB & HEARING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:LIEGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-729-5757
Mailing Address - Street 1:111 HULST DR STE 706
Mailing Address - Street 2:KMART WESTFALL SHOPPING CENTER
Mailing Address - City:MATAMORAS
Mailing Address - State:PA
Mailing Address - Zip Code:18336-2115
Mailing Address - Country:US
Mailing Address - Phone:570-491-5454
Mailing Address - Fax:570-491-2895
Practice Address - Street 1:111 HULST DR STE 706
Practice Address - Street 2:KMART WESTFALL SHOPPING CENTER
Practice Address - City:MATAMORAS
Practice Address - State:PA
Practice Address - Zip Code:18336-2115
Practice Address - Country:US
Practice Address - Phone:570-491-5454
Practice Address - Fax:570-491-2895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1294920001Medicare NSC
PA024162Medicare PIN