Provider Demographics
NPI:1801197678
Name:ENDLESS MOUNTAINS EYE CARE, LLC
Entity Type:Organization
Organization Name:ENDLESS MOUNTAINS EYE CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NIKKI
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-673-8390
Mailing Address - Street 1:327 SPRINGBROOK DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:PA
Mailing Address - Zip Code:17724-7896
Mailing Address - Country:US
Mailing Address - Phone:570-673-8390
Mailing Address - Fax:570-673-4606
Practice Address - Street 1:327 SPRINGBROOK DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:PA
Practice Address - Zip Code:17724-7896
Practice Address - Country:US
Practice Address - Phone:570-673-8390
Practice Address - Fax:570-673-4606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-10
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG-000540152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019750970005Medicaid
PA0019750970005Medicaid