Provider Demographics
NPI:1861795510
Name:LYNN PAVLIC, OD LLC
Entity type:Organization
Organization Name:LYNN PAVLIC, OD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:PAVLIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-225-4440
Mailing Address - Street 1:150 W BEAU ST
Mailing Address - Street 2:SUITE 112
Mailing Address - City:WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15301-4425
Mailing Address - Country:US
Mailing Address - Phone:724-225-4440
Mailing Address - Fax:724-225-5125
Practice Address - Street 1:150 W BEAU ST
Practice Address - Street 2:SUITE 112
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301-4425
Practice Address - Country:US
Practice Address - Phone:724-225-4440
Practice Address - Fax:724-225-5125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-17
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0E007059T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012949600001Medicaid
PA0012949600001Medicaid