Provider Demographics
NPI:1609061019
Name:VISTA OPTOMETRY, LLC
Entity Type:Organization
Organization Name:VISTA OPTOMETRY, LLC
Other - Org Name:WISE OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MENELAOS
Authorized Official - Middle Name:
Authorized Official - Last Name:LIULIAS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:724-612-3711
Mailing Address - Street 1:8131 POST RD
Mailing Address - Street 2:
Mailing Address - City:ALLISON PARK
Mailing Address - State:PA
Mailing Address - Zip Code:15101-3334
Mailing Address - Country:US
Mailing Address - Phone:724-612-3711
Mailing Address - Fax:724-458-0335
Practice Address - Street 1:15 PINE GROVE SQ
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:PA
Practice Address - Zip Code:16127-4447
Practice Address - Country:US
Practice Address - Phone:724-458-0333
Practice Address - Fax:724-458-0335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001284152W00000X, 152WC0802X, 152WX0102X
OH5728152W00000X
OHT2642152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
No152WX0102XEye and Vision Services ProvidersOptometristOccupational VisionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA400553OtherUPMC HEALTH PLAN
PA1982534OtherHIGHMARK BC/BS
PA1138132OtherHEALTH AMERICA
PATBDMedicaid
PA1982534OtherHIGHMARK BC/BS