Provider Demographics
NPI:1982942710
Name:CLASSIC OPTICAL INC.
Entity Type:Organization
Organization Name:CLASSIC OPTICAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:AYODALE
Authorized Official - Middle Name:CASTILLO
Authorized Official - Last Name:TAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-722-2242
Mailing Address - Street 1:6516 RISING SUN AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19111-5245
Mailing Address - Country:US
Mailing Address - Phone:215-722-2242
Mailing Address - Fax:215-722-6544
Practice Address - Street 1:6516 RISING SUN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-5245
Practice Address - Country:US
Practice Address - Phone:215-722-2242
Practice Address - Fax:215-722-6544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-29
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA296279Medicare PIN