Healthcare Provider Details

I. General information

NPI: 1881166643
Provider Name (Legal Business Name): MAIN STREET EYE CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2018
Last Update Date: 12/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S MAIN ST
DU BOIS PA
15801-1578
US

IV. Provider business mailing address

200 S MAIN ST
DU BOIS PA
15801-1578
US

V. Phone/Fax

Practice location:
  • Phone: 814-375-0125
  • Fax: 814-375-2291
Mailing address:
  • Phone: 814-375-0125
  • Fax: 814-375-2291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. CHRISTOPHER THOMAS SHAW
Title or Position: OWNER/OPTOMETRIST
Credential: OD
Phone: 814-375-0125