Healthcare Provider Details

I. General information

NPI: 1588708416
Provider Name (Legal Business Name): RAEBERN OPTICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 SOLLY AVE
PHILADELPHIA PA
19152-2804
US

IV. Provider business mailing address

2101 SOLLY AVE
PHILADELPHIA PA
19152-2804
US

V. Phone/Fax

Practice location:
  • Phone: 215-745-1996
  • Fax: 215-745-1996
Mailing address:
  • Phone: 215-745-1996
  • Fax: 215-745-1996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name: MRS. RIVKA GOLDMAN
Title or Position: PARTNER
Credential:
Phone: 215-745-1996