Provider Demographics
NPI:1992090096
Name:BEN DOMIANO OPTICAL CENTER LLC
Entity type:Organization
Organization Name:BEN DOMIANO OPTICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMIANO
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC
Authorized Official - Phone:570-457-2020
Mailing Address - Street 1:817 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OLD FORGE
Mailing Address - State:PA
Mailing Address - Zip Code:18518-1431
Mailing Address - Country:US
Mailing Address - Phone:570-457-2020
Mailing Address - Fax:570-457-2787
Practice Address - Street 1:817 S MAIN ST
Practice Address - Street 2:
Practice Address - City:OLD FORGE
Practice Address - State:PA
Practice Address - Zip Code:18518-1431
Practice Address - Country:US
Practice Address - Phone:570-457-2020
Practice Address - Fax:570-457-2787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-16
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000082152W00000X
PA30685156FC0800X, 156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact LensGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1C078666Medicare PIN