Provider Demographics
NPI:1174787873
Name:TRICE PROFESSIONAL OPTICAL
Entity type:Organization
Organization Name:TRICE PROFESSIONAL OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:DWAINE
Authorized Official - Last Name:BERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-836-2190
Mailing Address - Street 1:PO BOX 543
Mailing Address - Street 2:35 N MAIN STREET
Mailing Address - City:GREENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15601-0543
Mailing Address - Country:US
Mailing Address - Phone:724-836-2190
Mailing Address - Fax:724-836-2127
Practice Address - Street 1:35 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15601-2401
Practice Address - Country:US
Practice Address - Phone:724-836-2190
Practice Address - Fax:724-836-2127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-11
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA6000001146156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1298000001Medicare UPIN
PA1298000001Medicare NSC