Healthcare Provider Details

I. General information

NPI: 1467860155
Provider Name (Legal Business Name): DOCTOR OF EYEBALLS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2014
Last Update Date: 12/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

828 FAYETTE ST
CONSHOHOCKEN PA
19428-1709
US

IV. Provider business mailing address

828 FAYETTE ST
CONSHOHOCKEN PA
19428-1709
US

V. Phone/Fax

Practice location:
  • Phone: 610-828-9701
  • Fax: 610-828-4157
Mailing address:
  • Phone: 610-828-9701
  • Fax: 610-828-4157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG001838
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOEG001838
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License NumberOEG001838
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberOEG001838
License Number StatePA
# 5
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License NumberOEG001838
License Number StatePA
# 6
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License NumberOEG001838
License Number StatePA
# 7
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License NumberOEG001838
License Number StatePA
# 8
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberOEG001838
License Number StatePA

VIII. Authorized Official

Name: DR. BRETT NEAL
Title or Position: PRESIDENT
Credential: OD
Phone: 610-828-9701