Healthcare Provider Details

I. General information

NPI: 1770810681
Provider Name (Legal Business Name): KISSEL VILLAGE EYE CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2009
Last Update Date: 04/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1026 LITITZ PIKE
LITITZ PA
17543-9328
US

IV. Provider business mailing address

1026 LITITZ PIKE
LITITZ PA
17543-9328
US

V. Phone/Fax

Practice location:
  • Phone: 717-625-4989
  • Fax: 717-625-7360
Mailing address:
  • Phone: 717-625-4989
  • Fax: 717-625-7360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License NumberOEG001123
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KATHRYN E COLLINS
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 717-625-4989