=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952567968
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE EYEGALSS WORKS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2008
-----------------------------------------------------
Last Update Date | 07/30/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4407 MAIN ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19127-1311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-487-2711
-----------------------------------------------------
Fax | 215-487-3647
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4407 MAIN ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19127-1311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-487-2711
-----------------------------------------------------
Fax | 215-487-3647
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. JACK GOLDBERG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 215-487-2711
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------