=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225250566
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | B & C EYEGLASS FACTORY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2007
-----------------------------------------------------
Last Update Date | 07/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 E WYNNEWOOD RD
-----------------------------------------------------
City | WYNNEWOOD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19096-2013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-896-4542
-----------------------------------------------------
Fax | 610-896-4542
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 50 E WYNNEWOOD RD
-----------------------------------------------------
City | WYNNEWOOD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19096-2013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-896-4542
-----------------------------------------------------
Fax | 610-896-4542
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. BRUCE GOLDMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 610-896-4540
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 6000000032
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 6000000032
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------