1437348539 NPI number — WYOMISSING OPTOMETRIC CENTER, INC.

Table of content: CARLITA JACKSON (NPI 1255147500)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437348539 NPI number — WYOMISSING OPTOMETRIC CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WYOMISSING OPTOMETRIC CENTER, 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:
1437348539
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/04/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
50 BERKSHIRE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WYOMISSING
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19610-1219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-374-3134
Provider Business Mailing Address Fax Number:
610-374-0484

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1050 BENJAMIN FRANKLIN HIGHWAY WEST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOUGLASSVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19518
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-385-4333
Provider Business Practice Location Address Fax Number:
610-385-0484
Provider Enumeration Date:
10/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CORBIN
Authorized Official First Name:
GLENN
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
610-374-3134

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1366404345 . This is a "GEISINGER HEALTH PLAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1366404345 . This is a "HUMANA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0020572000 . This is a "INEPENDENCE BC/BS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1366404345 . This is a "CIGNA HEALTHCARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 29436 . This is a "SPECTERA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 338133 . This is a "HEALTH AMERICA/HEALTH ASS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1366404345 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 5586009 . This is a "AETNA TRADITIONAL/PPO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 02525100 . This is a "KEYSTONE SENIOR BLUE GROUP #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1366404345 . This is a "BERKSHIRE HEALTH PARTNERS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1366404345 . This is a "SECURE HORIZON" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: CM6302 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0020592000 . This is a "KEYSTONE EAST GROUP #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 429305 . This is a "HIGHMARK/BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 54384 . This is a "DAVIS AFFINITY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 02525100 . This is a "CAPITOL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0020592000 . This is a "AMERIHEALTH GROUP #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0050038 . This is a "AETNA/HMO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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