Healthcare Provider Details

I. General information

NPI: 1366627275
Provider Name (Legal Business Name): BOARDMAN FAMILY EYE CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2008
Last Update Date: 10/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

889 CRAFTMASTER ROAD
WYSOX PA
18854-0000
US

IV. Provider business mailing address

889 CRAFTMASTER ROAD PO BOX 331
WYSOX PA
18854-0000
US

V. Phone/Fax

Practice location:
  • Phone: 570-265-3668
  • Fax: 570-265-8936
Mailing address:
  • Phone: 570-265-3668
  • Fax: 570-265-8936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG000896
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberOEG000896
License Number StatePA

VIII. Authorized Official

Name: AVERY BOARDMAN
Title or Position: OWNER
Credential: OD
Phone: 570-265-3668