Healthcare Provider Details

I. General information

NPI: 1558344705
Provider Name (Legal Business Name): PHILLIP LEE WISE O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 04/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

326 N BROAD ST
SELINSGROVE PA
17870-1512
US

IV. Provider business mailing address

326 N BROAD ST
SELINSGROVE PA
17870-1512
US

V. Phone/Fax

Practice location:
  • Phone: 570-374-8136
  • Fax: 570-374-0462
Mailing address:
  • Phone: 570-374-8136
  • Fax: 570-374-0462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG001746
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: