Healthcare Provider Details

I. General information

NPI: 1457380552
Provider Name (Legal Business Name): PHILADELPHIA VISION CENTER OF MONTGOMERY COUNTY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 08/29/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 W CHELTENHAM AVE SUITE 230
WYNCOTE PA
19095-2946
US

IV. Provider business mailing address

2401 W CHELTENHAM AVE STE 230
WYNCOTE PA
19095-2946
US

V. Phone/Fax

Practice location:
  • Phone: 215-885-8500
  • Fax:
Mailing address:
  • Phone: 215-885-8500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOB007398A
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier01430122
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: MR. DAVID BOISSELLE
Title or Position: OWNER
Credential:
Phone: 215-885-8500