Provider Demographics
NPI:1972615680
Name:EYE MASTERS VISION CENTER, LLC
Entity Type:Organization
Organization Name:EYE MASTERS VISION CENTER, LLC
Other - Org Name:WILLOW EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:B
Authorized Official - Last Name:OKOREN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:215-659-1155
Mailing Address - Street 1:2300 COMPUTER AVENUE
Mailing Address - Street 2:SUITE A2
Mailing Address - City:WILLOW GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19090-1733
Mailing Address - Country:US
Mailing Address - Phone:215-659-1155
Mailing Address - Fax:215-659-1178
Practice Address - Street 1:2300 COMPUTER AVENUE
Practice Address - Street 2:SUITE A2
Practice Address - City:WILLOW GROVE
Practice Address - State:PA
Practice Address - Zip Code:19090-1733
Practice Address - Country:US
Practice Address - Phone:215-659-1155
Practice Address - Fax:215-659-1178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000124152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA091742Medicare PIN