Provider Demographics
NPI:1003196155
Name:CREIGHTON OPTICAL
Entity Type:Organization
Organization Name:CREIGHTON OPTICAL
Other - Org Name:DBA KEVIN CREIGHTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:F
Authorized Official - Last Name:CREIGHTON
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:716-937-7373
Mailing Address - Street 1:13375 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:ALDEN
Mailing Address - State:NY
Mailing Address - Zip Code:14004-1410
Mailing Address - Country:US
Mailing Address - Phone:716-937-7373
Mailing Address - Fax:716-937-4136
Practice Address - Street 1:13375 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:ALDEN
Practice Address - State:NY
Practice Address - Zip Code:14004-1410
Practice Address - Country:US
Practice Address - Phone:716-937-7373
Practice Address - Fax:716-937-4136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-22
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006357332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier