=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598402091
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CEDAR SEE VISION CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2022
-----------------------------------------------------
Last Update Date | 05/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5435 PETERSON RD
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19709-8953
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-609-0041
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8 THE GRN STE B
-----------------------------------------------------
City | DOVER
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19901-3618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | DR. WITHNEY KORLEY
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 302-609-0041
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------