MEDICARE: EYETIQUE INC

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	:	1841789278
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYETIQUE INC

Provider Business Mailing Address
First Line	:	211 E BROADWAY
Second Line	:
City	:	ALTON
State	:	IL
Zip	:	62002-6220
Country	:	US
Telephone Number	:	618-462-9818
Fax Number	:	314-741-4947

Provider Business Practice Location Address
First Line	:	3701 FORBES AVE
Second Line	:
City	:	PITTSBURGH
State	:	PA
Zip	:	15213
Country	:	US
Telephone Number	:	412-682-1499
Fax Number	:	412-682-4599

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	CATHY L SHORT
Credential	:
Telephone Number	:	618-462-9818

Provider Enumeration Date	:	05/01/2018
Last Update Date	:	07/15/2020

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Directions to “EYETIQUE INC ” Practice Location

Language	Start Address	Practice Location

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