1154370468 NPI number — OPTOMETRIC PROVIDERS INC

Table of content: (NPI 1154370468)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154370468 NPI number — OPTOMETRIC PROVIDERS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTOMETRIC PROVIDERS INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154370468
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2921 ERIE BLVD E
Provider Second Line Business Mailing Address:
OPTOMETRIC PROVIDERS INC
Provider Business Mailing Address City Name:
SYRACUSE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13224
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-446-3145
Provider Business Mailing Address Fax Number:
315-445-7675

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17 DAVIS STRAIGHTS RD
Provider Second Line Business Practice Location Address:
RTE 28
Provider Business Practice Location Address City Name:
FALMOUTH
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02540
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-495-0332
Provider Business Practice Location Address Fax Number:
508-548-9821
Provider Enumeration Date:
05/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
IACOBBO
Authorized Official First Name:
ALERINO
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
315-446-3145

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9781048 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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