1669599247 NPI number — DAVISON ROAD OPTICAL INC

Table of content: (NPI 1669599247)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669599247 NPI number — DAVISON ROAD OPTICAL INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVISON ROAD OPTICAL 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:
6
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:
1669599247
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2731 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWFANE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14108-1203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-778-0926
Provider Business Mailing Address Fax Number:
716-778-0926

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2731 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWFANE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14108-1203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-778-0926
Provider Business Practice Location Address Fax Number:
716-778-0926
Provider Enumeration Date:
03/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SNYDER
Authorized Official First Name:
GENEVIEVE
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
716-434-8063

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 149010 . This is a "COLE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: NY3149 . This is a "EYEMED LOCATION #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000300233002 . This is a "BC-BS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0005901355 . This is a "AETNA GROUP #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 145817C . This is a "PREFFERED CARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1071 . This is a "UNIVERA PIN #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 330868 . This is a "NVA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: OS0044759 . This is a "INDEPENDENT HEALTH RX #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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