MEDICARE: PINE VISION CARE PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist

General Provider Information

NPI Number	:	1316426240
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PINE VISION CARE PC

Provider Business Mailing Address
First Line	:	1018 PINE ST FL 1
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19107-6069
Country	:	US
Telephone Number	:	215-575-5198
Fax Number	:	215-982-1193

Provider Business Practice Location Address
First Line	:	1018 PINE ST FL 1
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19107-6069
Country	:	US
Telephone Number	:	215-575-5198
Fax Number	:	215-982-1193

Authorized Official
Title or Position	:	CEO
Name	:	JULIA ZYRINA
Credential	:	OD
Telephone Number	:	215-575-5198

Provider Enumeration Date	:	08/10/2018
Last Update Date	:	01/09/2019

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