Provider Demographics
NPI:1124105325
Name:BEAVER EYEWEAR, INC.
Entity type:Organization
Organization Name:BEAVER EYEWEAR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:BEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-322-1220
Mailing Address - Street 1:1705 WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-2647
Mailing Address - Country:US
Mailing Address - Phone:570-322-1220
Mailing Address - Fax:570-322-3454
Practice Address - Street 1:1705 WARREN AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-2647
Practice Address - Country:US
Practice Address - Phone:570-322-1220
Practice Address - Fax:570-322-3454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PANOT APPLICABLE156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0212530001Medicare ID - Type Unspecified
PA0212530001Medicare NSC