Provider Demographics
NPI:1497798177
Name:PATTY VISION CENTER OD PA
Entity Type:Organization
Organization Name:PATTY VISION CENTER OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AUGUSTA
Authorized Official - Middle Name:REID
Authorized Official - Last Name:PATTY
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:336-694-9632
Mailing Address - Street 1:495 HWY 158 WEST
Mailing Address - Street 2:
Mailing Address - City:YANCEYVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27379
Mailing Address - Country:US
Mailing Address - Phone:336-694-9632
Mailing Address - Fax:336-694-1207
Practice Address - Street 1:495 HWY 158 WEST
Practice Address - Street 2:
Practice Address - City:YANCEYVILLE
Practice Address - State:NC
Practice Address - Zip Code:27379
Practice Address - Country:US
Practice Address - Phone:336-694-9632
Practice Address - Fax:336-694-1207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1088152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0840870002Medicare NSC