Provider Demographics
NPI:1053458810
Name:FAMILY OPTICAL CENTER PC
Entity Type:Organization
Organization Name:FAMILY OPTICAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:RAYE
Authorized Official - Last Name:SCHRECK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:814-336-6353
Mailing Address - Street 1:PO BOX 867
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-6867
Mailing Address - Country:US
Mailing Address - Phone:814-336-6353
Mailing Address - Fax:814-336-6354
Practice Address - Street 1:900 WATER ST
Practice Address - Street 2:DOWNTOWN MALL
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-3428
Practice Address - Country:US
Practice Address - Phone:814-336-6353
Practice Address - Fax:814-336-6354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000441152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1012934830001Medicaid
PA1012934830001Medicaid
PA5484360001Medicare NSC
PA091231Medicare ID - Type Unspecified