Healthcare Provider Details

I. General information

NPI: 1104510569
Provider Name (Legal Business Name): AVERSTIN EYE GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2023
Last Update Date: 06/07/2023
Certification Date: 05/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2571 US-6 101
HAWLEY PA
18428
US

IV. Provider business mailing address

1421 MAIN ST
PECKVILLE PA
18452-2008
US

V. Phone/Fax

Practice location:
  • Phone: 570-226-2400
  • Fax:
Mailing address:
  • Phone: 570-382-3922
  • Fax: 570-393-7585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State

VIII. Authorized Official

Name: JOHN J GLASNER
Title or Position: OWNER
Credential: OD
Phone: 570-369-3139