Provider Demographics
NPI:1205107356
Name:MOSHANNON VALLEY EYE CARE LLC
Entity type:Organization
Organization Name:MOSHANNON VALLEY EYE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:SHEDLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:814-378-7700
Mailing Address - Street 1:612 CLARA ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:HOUTZDALE
Mailing Address - State:PA
Mailing Address - Zip Code:16651-1115
Mailing Address - Country:US
Mailing Address - Phone:814-378-7700
Mailing Address - Fax:
Practice Address - Street 1:612 CLARA ST
Practice Address - Street 2:SUITE 1
Practice Address - City:HOUTZDALE
Practice Address - State:PA
Practice Address - Zip Code:16651-1115
Practice Address - Country:US
Practice Address - Phone:814-378-7700
Practice Address - Fax:814-378-7704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-21
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG-002053152W00000X
PAOEG-002084152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty