Provider Demographics
NPI:1285767814
Name:PRO VISION OPTOMETRIC CENTER PA
Entity type:Organization
Organization Name:PRO VISION OPTOMETRIC CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:PESTEANU
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:252-519-9401
Mailing Address - Street 1:12 ANNA LOUISE LN
Mailing Address - Street 2:
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870-8648
Mailing Address - Country:US
Mailing Address - Phone:252-519-9401
Mailing Address - Fax:252-519-9404
Practice Address - Street 1:12 ANNA LOUISE LN
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-8648
Practice Address - Country:US
Practice Address - Phone:252-519-9401
Practice Address - Fax:252-519-9404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1506152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890243LMedicaid
NC890928EMedicaid
NC890928EMedicaid
NC890243LMedicaid