Healthcare Provider Details

I. General information

NPI: 1427226281
Provider Name (Legal Business Name): TOM GRUDIS OPTICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2008
Last Update Date: 02/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 SPRUCE STREET
SCRANTON PA
18503-1821
US

IV. Provider business mailing address

428 SPRUCE STREET
SCRANTON PA
18503-1821
US

V. Phone/Fax

Practice location:
  • Phone: 570-346-1771
  • Fax: 570-346-5812
Mailing address:
  • Phone: 570-346-1771
  • Fax: 570-346-5812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number156FX1800X
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MRS. CAROL KOONS
Title or Position: BOOKKEEPER
Credential:
Phone: 570-346-1771