Provider Demographics
NPI:1104373265
Name:HEAVENLY VISION
Entity Type:Organization
Organization Name:HEAVENLY VISION
Other - Org Name:BLUE VALLEY VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTICIAN / OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:VELEKEI
Authorized Official - Suffix:SR
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:610-432-7000
Mailing Address - Street 1:455 BLUE VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:PA
Mailing Address - Zip Code:18013-1513
Mailing Address - Country:US
Mailing Address - Phone:610-432-7000
Mailing Address - Fax:
Practice Address - Street 1:455 BLUE VALLEY DR
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:PA
Practice Address - Zip Code:18013
Practice Address - Country:US
Practice Address - Phone:610-432-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLUE VALLEY VISION LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA046078156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA13658572OtherCAQH