Healthcare Provider Details

I. General information

NPI: 1265861330
Provider Name (Legal Business Name): EYETIQUE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2013
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28699 CHAGRIN BLVD SUITE 400
WOODMERE OH
44122
US

IV. Provider business mailing address

2242 MURRAY AVE
PITTSBURGH PA
15217-2308
US

V. Phone/Fax

Practice location:
  • Phone: 216-514-3002
  • Fax: 216-514-1483
Mailing address:
  • Phone: 412-422-5300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: CATHY L SHORT
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 618-462-9818