Provider Demographics
NPI:1699060335
Name:MARY REED DACANAL OD INC.
Entity type:Organization
Organization Name:MARY REED DACANAL OD INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:DACANAL
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:814-772-0674
Mailing Address - Street 1:20 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:RIDGWAY
Mailing Address - State:PA
Mailing Address - Zip Code:15853-8018
Mailing Address - Country:US
Mailing Address - Phone:814-772-0674
Mailing Address - Fax:
Practice Address - Street 1:20 N BROAD ST
Practice Address - Street 2:
Practice Address - City:RIDGWAY
Practice Address - State:PA
Practice Address - Zip Code:15853-8018
Practice Address - Country:US
Practice Address - Phone:814-772-0674
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-10
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000721152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA4928380002Medicare NSC