Provider Demographics
NPI:1467967794
Name:VISION SOURCE MEADVILLE LLC
Entity Type:Organization
Organization Name:VISION SOURCE MEADVILLE LLC
Other - Org Name:VISION SOURCE TITUSVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:ADSIT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-333-6606
Mailing Address - Street 1:1073 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-3129
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1073 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-3129
Practice Address - Country:US
Practice Address - Phone:814-333-6606
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VISION SOURCE MEADVILLE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-12-08
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000417152W00000X
PAOEG002385152W00000X
PAOEG000659152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1031405540001Medicaid