Healthcare Provider Details

I. General information

NPI: 1952541955
Provider Name (Legal Business Name): EYETIQUE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2009
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 5TH AVE
PITTSBURGH PA
15222
US

IV. Provider business mailing address

208 5TH AVE
PITTSBURGH PA
15222-2701
US

V. Phone/Fax

Practice location:
  • Phone: 412-281-9199
  • Fax: 412-281-9210
Mailing address:
  • Phone: 412-281-9199
  • Fax: 412-281-9210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOE006128P
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number6000002687
License Number StatePA

VIII. Authorized Official

Name: CATHY L SHORT
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 618-462-9818