Provider Demographics
NPI:1568898690
Name:WEST PENN ADVANCE VISION CARE & OPTICAL LLC
Entity Type:Organization
Organization Name:WEST PENN ADVANCE VISION CARE & OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:814-833-1194
Mailing Address - Street 1:2576 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-4416
Mailing Address - Country:US
Mailing Address - Phone:814-833-1194
Mailing Address - Fax:814-838-9530
Practice Address - Street 1:2576 W 8TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-4416
Practice Address - Country:US
Practice Address - Phone:814-833-1194
Practice Address - Fax:814-838-9530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-20
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000497152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty