Provider Demographics
NPI:1578034187
Name:CENTRAL VISION EYECARE LLC
Entity Type:Organization
Organization Name:CENTRAL VISION EYECARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:TERA
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:UNZICKER-FASSERO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:570-768-4970
Mailing Address - Street 1:416 MARKET ST STE 214
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17837-1473
Mailing Address - Country:US
Mailing Address - Phone:570-768-4970
Mailing Address - Fax:
Practice Address - Street 1:23 S ARCH ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:PA
Practice Address - Zip Code:17847-1124
Practice Address - Country:US
Practice Address - Phone:570-412-1346
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-07
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102551143Medicaid