Provider Demographics
NPI:1790416873
Name:CEREO, MICHELLE (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:CEREO
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 HERITAGE DR
Mailing Address - Street 2:
Mailing Address - City:SANATOGA
Mailing Address - State:PA
Mailing Address - Zip Code:19464-9216
Mailing Address - Country:US
Mailing Address - Phone:610-326-2754
Mailing Address - Fax:
Practice Address - Street 1:1100 HERITAGE DR
Practice Address - Street 2:
Practice Address - City:SANATOGA
Practice Address - State:PA
Practice Address - Zip Code:19464-9216
Practice Address - Country:US
Practice Address - Phone:610-326-2754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY9996156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician