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General NPI Number Information
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NPI Number | 1528833167
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Entity Type | Organization
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Legal Business Name | AEG PENNSYLVANIA PROFESSIONAL, INC
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Dates
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Enumeration Date | 11/22/2023
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Last Update Date | 11/22/2023
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Provider Practice Location Address
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Address Line | 1450 E BOOT RD STE 700B
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City | WEST CHESTER
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State | PA
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Zip | 19380-5942
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Country | US
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Telephone | 610-696-1368
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Fax |
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Provider Business Mailing Address
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Address Line | 111 E 4TH ST STE 440
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City | ALTON
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State | IL
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Zip | 62002-6206
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Country | US
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Telephone | 618-462-9818
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Fax | 314-741-4947
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Authorized Official
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Title or Position | PRESIDENT
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Name | BENJAMIN CHUDNER
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Credential |
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Telephone | 314-741-4947
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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 |
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License Number State |
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