Healthcare Provider Details

I. General information

NPI: 1639047426
Provider Name (Legal Business Name): ALICE MUNGYU
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2025
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8360 OLD YORK RD
ELKINS PARK PA
19027-1576
US

IV. Provider business mailing address

8360 OLD YORK RD
ELKINS PARK PA
19027-1576
US

V. Phone/Fax

Practice location:
  • Phone: 215-780-1400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number011391
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: