Provider Demographics
NPI:1841431970
Name:C-WELLOPTICAL
Entity Type:Organization
Organization Name:C-WELLOPTICAL
Other - Org Name:NA
Other - Org Type:Other Name
Authorized Official - Title/Position:OPTICAN
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:MISKE
Authorized Official - Suffix:JR
Authorized Official - Credentials:OPTICAN
Authorized Official - Phone:570-622-0226
Mailing Address - Street 1:109 PIKE ST
Mailing Address - Street 2:
Mailing Address - City:PORT CARBON
Mailing Address - State:PA
Mailing Address - Zip Code:17965-1814
Mailing Address - Country:US
Mailing Address - Phone:570-622-0226
Mailing Address - Fax:570-622-9277
Practice Address - Street 1:109 PIKE ST
Practice Address - Street 2:
Practice Address - City:PORT CARBON
Practice Address - State:PA
Practice Address - Zip Code:17965-1814
Practice Address - Country:US
Practice Address - Phone:570-622-0226
Practice Address - Fax:570-622-9277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-19
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA6000000546332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0769520001Medicare NSC
PA0769520001Medicare UPIN