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General NPI Number Information
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NPI Number | 1396919825
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Entity Type | Organization
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Legal Business Name | KINGSTON OPHTHALMOLOGY ASC LLC
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Dates
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Enumeration Date | 04/16/2008
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Last Update Date | 09/07/2023
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Provider Practice Location Address
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Address Line | 601 WYOMING AVE
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City | KINGSTON
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State | PA
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Zip | 18704-3701
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Country | US
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Telephone | 570-288-7405
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Fax | 570-714-0419
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Provider Business Mailing Address
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Address Line | 601 WYOMING AVE
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City | KINGSTON
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State | PA
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Zip | 18704-3701
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Country | US
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Telephone | 570-288-7405
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Fax | 570-714-0419
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. PHILLIP A. CLENDENIN
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Credential |
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Telephone | 615-665-1283
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number |
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License Number State |
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