MEDICARE: VISIONCARE LASER CENTERS OF ERIE

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	OB007924A	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	205697	OTHER	PA	BCBS

General Provider Information

NPI Number	:	1427126267
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VISIONCARE LASER CENTERS OF ERIE

Provider Business Mailing Address
First Line	:	1909 WEST 8TH STREET
Second Line	:
City	:	ERIE
State	:	PA
Zip	:	16505-4936
Country	:	US
Telephone Number	:	814-454-7088
Fax Number	:	814-459-5189

Provider Business Practice Location Address
First Line	:	1909 WEST 8TH STREET
Second Line	:
City	:	ERIE
State	:	PA
Zip	:	16505-4936
Country	:	US
Telephone Number	:	814-454-7088
Fax Number	:	814-459-5189

Authorized Official
Title or Position	:	GENERAL MANAGER
Name	:	MR. JAMES THOMAS CANELLA
Credential	:
Telephone Number	:	814-454-7088

Provider Enumeration Date	:	12/01/2006
Last Update Date	:	08/22/2020

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