Provider Demographics
NPI:1417300849
Name:NOSTALGIC EYECARE INC
Entity Type:Organization
Organization Name:NOSTALGIC EYECARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:HERRING
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:718-825-2067
Mailing Address - Street 1:6656 GERMANTOWN AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-2163
Mailing Address - Country:US
Mailing Address - Phone:718-825-2067
Mailing Address - Fax:
Practice Address - Street 1:1319 BRUCE RD
Practice Address - Street 2:APARTMENT B
Practice Address - City:ORELAND
Practice Address - State:PA
Practice Address - Zip Code:19075-1819
Practice Address - Country:US
Practice Address - Phone:718-825-2067
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-20
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002906261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service