=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215524517
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTEGRATED VISION CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/22/2020
-----------------------------------------------------
Last Update Date | 12/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 431 SHAWNEE DR
-----------------------------------------------------
City | ERIE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16505-2433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-823-4486
-----------------------------------------------------
Fax | 814-454-7484
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 431 SHAWNEE DR
-----------------------------------------------------
City | ERIE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16505-2433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-823-4486
-----------------------------------------------------
Fax | 814-454-7484
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DOUGLAS VILLELLA
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 814-823-4486
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------