=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508088121
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LACKAWANNA EYE ASSOCIATES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 COMMERCE BLVD
-----------------------------------------------------
City | DICKSON CITY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-383-3373
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | RD 1 CRAIG ROAD BOX 307
-----------------------------------------------------
City | DALTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-371-5662
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. PAUL RAYMOND MONTAGUE
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 860-371-5662
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OEG001862
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------