Healthcare Provider Details

I. General information

NPI: 1821478736
Provider Name (Legal Business Name): EYETIQUE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2015
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5166 BUTLER ST
PITTSBURGH PA
15201
US

IV. Provider business mailing address

1201 BANKSVILLE RD
PITTSBURGH PA
15216-3009
US

V. Phone/Fax

Practice location:
  • Phone: 412-772-1473
  • Fax:
Mailing address:
  • Phone: 412-668-3917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: DANIEL CHILDS
Title or Position: OWNER/MANAGER
Credential:
Phone: 412-772-1473