MEDICARE: VISION INNOVATION CENTERS OF PENNSYLVANIA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician
2	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1871163113
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VISION INNOVATION CENTERS OF PENNSYLVANIA LLC

Provider Business Mailing Address
First Line	:	703 RUTTER AVE
Second Line	:
City	:	KINGSTON
State	:	PA
Zip	:	18704-4801
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	503 S STATE ST
Second Line	:
City	:	CLARKS SUMMIT
State	:	PA
Zip	:	18411-1557
Country	:	US
Telephone Number	:	570-587-5186
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	MICHAEL C PASCETTA
Credential	:
Telephone Number	:	860-652-5002

Provider Enumeration Date	:	06/29/2021
Last Update Date	:	04/09/2026

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