Provider Demographics
NPI:1437575230
Name:COLLEGEVILLE OPTICAL, LLC
Entity Type:Organization
Organization Name:COLLEGEVILLE OPTICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPHTHALMOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:WILTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-489-8137
Mailing Address - Street 1:753 W MAIN ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:TRAPPE
Mailing Address - State:PA
Mailing Address - Zip Code:19426-1948
Mailing Address - Country:US
Mailing Address - Phone:610-489-8137
Mailing Address - Fax:610-489-8139
Practice Address - Street 1:753 W MAIN ST
Practice Address - Street 2:SUITE D
Practice Address - City:TRAPPE
Practice Address - State:PA
Practice Address - Zip Code:19426-1948
Practice Address - Country:US
Practice Address - Phone:610-489-8137
Practice Address - Fax:610-489-8139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-17
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA5914840001Medicare NSC