Healthcare Provider Details

I. General information

NPI: 1710691761
Provider Name (Legal Business Name): HEATHER TELLEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2023
Last Update Date: 02/07/2023
Certification Date: 02/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 W GIRARD AVE STE 5
PHILADELPHIA PA
19123-1660
US

IV. Provider business mailing address

180 W GIRARD AVE STE 5
PHILADELPHIA PA
19123-1660
US

V. Phone/Fax

Practice location:
  • Phone: 215-554-6222
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG003892
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: