Basic Information
| Provider Information | |||||||||
| NPI: | 1528114311 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY EYE CARE SPECIALISTS, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 FARM COLONY DRIVE | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 163655206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147262303 | ||||||||
| FaxNumber: | 8147267459 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 FARM COLONY DRIVE | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 163655206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147262303 | ||||||||
| FaxNumber: | 8147267459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2007 | ||||||||
| LastUpdateDate: | 10/13/2021 | ||||||||
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| AuthorizedOfficialLastName: | WUEBBOLT | ||||||||
| AuthorizedOfficialFirstName: | GORDON | ||||||||
| AuthorizedOfficialMiddleName: | EDGAR | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7164846700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 09/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 156FX1100X | MD052930L | PA | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Technician/Technologist | Ophthalmic | 156FX1100X | MD065707L | PA | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Technician/Technologist | Ophthalmic | 163WA2000X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Administrator | 207WX0200X | N | 193200000X MULTI-SPECIALTY GROUP | 163WG0000X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | General Practice | 163WX1100X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Ophthalmic | 207W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 1548234255 | 01 | PA | WUEBBOLT NPI | OTHER |