Basic Information
| Provider Information | |||||||||
| NPI: | 1215028469 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEL VAL ASC LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | THE EYE SURGERY CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 MALL BLVD | ||||||||
| Address2: | |||||||||
| City: | KING OF PRUSSIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194062902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103371580 | ||||||||
| FaxNumber: | 6103372133 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 MALL BLVD | ||||||||
| Address2: | |||||||||
| City: | KING OF PRUSSIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194062902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103371580 | ||||||||
| FaxNumber: | 6103372133 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6104912127 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 1014257330001 | 05 | PA | MEDICAID |