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General NPI Number Information
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NPI Number | 1568898690
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Entity Type | Organization
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Legal Business Name | WEST PENN ADVANCE VISION CARE & OPTICAL LLC
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Dates
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Enumeration Date | 09/20/2013
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Last Update Date | 09/20/2013
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Provider Practice Location Address
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Address Line | 2576 W 8TH ST
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City | ERIE
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State | PA
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Zip | 16505-4416
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Country | US
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Telephone | 814-833-1194
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Fax | 814-838-9530
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Provider Business Mailing Address
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Address Line | 2576 W 8TH ST
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City | ERIE
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State | PA
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Zip | 16505-4416
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Country | US
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Telephone | 814-833-1194
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Fax | 814-838-9530
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Authorized Official
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Title or Position | OPTOMETRIST/OWNER
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Name | RENEE PETERSON
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Credential | OD
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Telephone | 814-833-1194
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OEG000497
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License Number State | PA
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