Organization Name: | SOUTH PARK OPTICAL, INC. |
NPI Number: | 1700974946 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | JAMES GORDON BEITER (OPTICIAN) |
Mailing Address: | 3861 S Park Ave Blasdell |
State: | NY US |
Postal Code: | 142191813 |
Phone Number: | 7168236093 |
Fax Number: | |
NPI Enumeration Date: | 10/11/2006 |
NPI Last Update Date: | 12/05/2014 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 156FX1800X |
License Number: | C-5093-1 |
Healthcare Provider Taxonomy: (Secondary) | N |
State: | NY |
Taxonomy Type: | Eye and Vision Services Providers |
Taxonomy Classification: | Technician/Technologist |
Taxonomy Specialization: | Optician |
Taxonomy Definition: |