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General NPI Number Information
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NPI Number | 1033404900
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Entity Type | Organization
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Legal Business Name | RUSSELL EYECARE INC.
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Dates
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Enumeration Date | 06/18/2011
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Last Update Date | 06/18/2011
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Provider Practice Location Address
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Address Line | 1450 MORRELL AVE
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City | CONNELLSVILLE
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State | PA
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Zip | 15425-3809
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Country | US
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Telephone | 724-626-4486
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Fax |
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Provider Business Mailing Address
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Address Line | 11 LINDSAY DR
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City | UNIONTOWN
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State | PA
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Zip | 15401-9430
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Country | US
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Telephone | 412-496-0327
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/ OPTOMETRIST
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Name | DR. BARRY DAVID RUSSELL
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Credential | O.D.
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Telephone | 412-496-0327
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152WC0802X
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Taxonomy Name | Corneal and Contact Management Optometrist
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License Number | OEG000421
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License Number State | PA
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