Organization
THOMAS C TREVORROW
Active
Organization subpart
No
Provider details
NPI number
Authorized official
THOMAS C TREVORROW (OWNER)
(724) 463-0286
Entity
Organization
Contact information
Practice address
119 PROFESSIONAL CTR, 1265 WAYNE AVENUE, SUITE 203, INDIANA, PA 15701-3586
(724) 463-0286
Mailing address
119 PROFESSIONAL CTR, 1265 WAYNE AVENUE, SUITE 203, INDIANA, PA 15701-3586
(724) 463-0286
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
MD049389L
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0014147820002
—
PA
01
—
1040831
GATEWAY PROVIDER
PA
01
—
735637
BLUE SHIELD
PA
01
—
735637-L3D
BLUE SHIELD PROVIDER
PA
Enumeration date
02/15/2008
Last updated
02/15/2008
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