Provider Demographics
NPI:1679661771
Name:JUDITH A WENTZEL
Entity Type:Organization
Organization Name:JUDITH A WENTZEL
Other - Org Name:MON VALLEY VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTICIAN OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:A
Authorized Official - Last Name:ZEWE
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:724-258-3773
Mailing Address - Street 1:120 MAIN STREET PO BOX 430
Mailing Address - Street 2:
Mailing Address - City:NEW EAGLE
Mailing Address - State:PA
Mailing Address - Zip Code:15067
Mailing Address - Country:US
Mailing Address - Phone:724-258-3773
Mailing Address - Fax:724-258-4805
Practice Address - Street 1:120 MAIN STREET
Practice Address - Street 2:
Practice Address - City:NEW EAGLE
Practice Address - State:PA
Practice Address - Zip Code:15067
Practice Address - Country:US
Practice Address - Phone:724-258-3773
Practice Address - Fax:724-258-4805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01741893Medicaid
14872OtherSPECTERA
49647OtherDAVIS VISION
PA01741893Medicaid