Healthcare Provider Details

I. General information

NPI: 1972882942
Provider Name (Legal Business Name): BISTLINE VISION CARE ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2011
Last Update Date: 08/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W GERMANTOWN PIKE SPACE 2230
PLYMOUTH MEETING PA
19462-1353
US

IV. Provider business mailing address

500 W GERMANTOWN PIKE SPACE 2230
PLYMOUTH MEETING PA
19462-1353
US

V. Phone/Fax

Practice location:
  • Phone: 610-941-0335
  • Fax: 610-941-9534
Mailing address:
  • Phone: 610-941-0335
  • Fax: 610-941-9534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG002052
License Number StatePA

VIII. Authorized Official

Name: KEVIN BISTLINE
Title or Position: OWNER
Credential: O.D.
Phone: 610-941-0335