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General NPI Number Information
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NPI Number | 1205015815
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Entity Type | Organization
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Legal Business Name | PRIMARY EYE CARE CENTER PC
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Dates
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Enumeration Date | 10/31/2007
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Last Update Date | 03/28/2011
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Provider Practice Location Address
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Address Line | 405 S MARKET ST
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City | ELIZABETHTOWN
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State | PA
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Zip | 17022
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Country | US
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Telephone | 717-367-1883
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Fax | 717-367-1884
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Provider Business Mailing Address
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Address Line | 405 S MARKET ST
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City | ELIZABETHTOWN
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State | PA
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Zip | 17022
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Country | US
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Telephone | 717-367-1883
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Fax | 717-367-1884
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. TY M GRADEN
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Credential | OD
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Telephone | 717-367-1883
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 0E007020T
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License Number State | PA
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