=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821478736
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYETIQUE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2015
-----------------------------------------------------
Last Update Date | 07/15/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5166 BUTLER ST
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-772-1473
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1201 BANKSVILLE RD
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15216-3009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-668-3917
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MANAGER
-----------------------------------------------------
Name | DANIEL CHILDS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 412-772-1473
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------