1366566713 NPI number — OPTOMETRIC CARE, INC

Table of content: (NPI 1366566713)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366566713 NPI number — OPTOMETRIC CARE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTOMETRIC CARE, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366566713
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
102 WAGNER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONACA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15061-2456
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-774-7232
Provider Business Mailing Address Fax Number:
724-774-1856

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
102 WAGNER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONACA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15061-2456
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-774-7232
Provider Business Practice Location Address Fax Number:
724-774-1856
Provider Enumeration Date:
03/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WIGGINS
Authorized Official First Name:
NANCY
Authorized Official Middle Name:
P
Authorized Official Title or Position:
VICE PRESIDENT OF OCI
Authorized Official Telephone Number:
724-774-7232

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OEG001209 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: OEG000767 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152WC0802X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: OEG000668 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0019390180002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 71433 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1392079 . This is a "HIGHMARK BCBS MD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 137838 . This is a "ADVANTRA HEALTH AMERICA" identifier , issued by the state of ( PW ) . This identifiers is of the category "OTHER".
  • Identifier: 030648 . This is a "HIGHMARK BCBS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: PA4436 . This is a "EYEMED" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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