Provider Demographics
NPI:1306071766
Name:COLUMBUS LASER VISION
Entity type:Organization
Organization Name:COLUMBUS LASER VISION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:COLUMBUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-824-3500
Mailing Address - Street 1:342 WILKES BARRE TOWNSHIP BLVD
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-6708
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:342 WILKES BARRE TOWNSHIP BLVD
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-6708
Practice Address - Country:US
Practice Address - Phone:570-824-3500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-28
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD072154L174400000X
PAOEG0001371152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty