Healthcare Provider Details

I. General information

NPI: 1720066392
Provider Name (Legal Business Name): WYOMING VALLEY PET ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 06/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 WELLES ST
FORTY FORT PA
18704-4968
US

IV. Provider business mailing address

43 LEOPARD RD SUITE 200
PAOLI PA
19301-1552
US

V. Phone/Fax

Practice location:
  • Phone: 570-331-7702
  • Fax: 570-331-7704
Mailing address:
  • Phone: 610-993-1640
  • Fax: 610-993-1651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. EDWARD J GRACE
Title or Position: DIRECTOR OF BILLING
Credential:
Phone: 610-993-1640