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General NPI Number Information
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NPI Number | 1982732715
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Entity Type | Organization
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Legal Business Name | CUSTOM EYES RX INC
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Dates
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Enumeration Date | 03/01/2007
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Last Update Date | 06/23/2008
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Provider Practice Location Address
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Address Line | 111 HULST DR STE 706 KMART WESTFALL SHOPPING CENTER
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City | MATAMORAS
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State | PA
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Zip | 18336-2115
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Country | US
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Telephone | 570-491-5454
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Fax | 570-491-2895
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Provider Business Mailing Address
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Address Line | 111 HULST DR STE 706 KMART WESTFALL SHOPPING CENTER
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City | MATAMORAS
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State | PA
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Zip | 18336-2115
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Country | US
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Telephone | 570-491-5454
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Fax | 570-491-2895
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. JEFFREY TODD LIEGNER
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Credential | MD
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Telephone | 973-729-5757
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number |
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License Number State |
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