MEDICARE: EYETIQUE CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist

General Provider Information

NPI Number	:	1598008526
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYETIQUE CORP

Provider Business Mailing Address
First Line	:	2242 MURRAY AVE
Second Line	:
City	:	PITTSBURGH
State	:	PA
Zip	:	15217-2308
Country	:	US
Telephone Number	:	412-422-5300
Fax Number	:

Provider Business Practice Location Address
First Line	:	3001 WATERDAM PLAZA DR
Second Line	:	SUITE 120, ROUTE19
City	:	MC MURRAY
State	:	PA
Zip	:	15317-5415
Country	:	US
Telephone Number	:	724-260-0243
Fax Number	:

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MR. BRAD CHILDS
Credential	:
Telephone Number	:	412-422-5300

Provider Enumeration Date	:	03/28/2013
Last Update Date	:	03/19/2014

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Directions to “EYETIQUE CORP ” Practice Location

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