Healthcare Provider Details

I. General information

NPI: 1104103456
Provider Name (Legal Business Name): PRESQUE ISLE OPTIQUE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2011
Last Update Date: 11/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 W 18TH ST
ERIE PA
16501-2103
US

IV. Provider business mailing address

147 W 18TH ST
ERIE PA
16501-2103
US

V. Phone/Fax

Practice location:
  • Phone: 814-454-7138
  • Fax:
Mailing address:
  • Phone: 814-454-7138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEGOO1057
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License Number
License Number State

VIII. Authorized Official

Name: MR. GERALD M. STEFANIC
Title or Position: OPTICIAN/OWNER
Credential:
Phone: 814-454-7138