Provider Demographics
NPI:1942480371
Name:GWEN VINROE COLTZ, O.D., LLC
Entity Type:Organization
Organization Name:GWEN VINROE COLTZ, O.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:GWEN
Authorized Official - Middle Name:VINROE
Authorized Official - Last Name:COLTZ
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:814-226-3937
Mailing Address - Street 1:100 WEST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:CLARION
Mailing Address - State:PA
Mailing Address - Zip Code:16214
Mailing Address - Country:US
Mailing Address - Phone:814-226-3937
Mailing Address - Fax:
Practice Address - Street 1:100 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CLARION
Practice Address - State:PA
Practice Address - Zip Code:16214-1070
Practice Address - Country:US
Practice Address - Phone:814-226-3937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000433152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADE3926OtherPALMETTO GBA- RAILROAD
PA082782Medicare PIN
PADE3926OtherPALMETTO GBA- RAILROAD
PA5697500001Medicare NSC