Provider Demographics
NPI:1013044544
Name:MEDINA OPTICAL FASHIONS, INC.
Entity Type:Organization
Organization Name:MEDINA OPTICAL FASHIONS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT TREASURE
Authorized Official - Prefix:MS
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:RISHEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-944-2219
Mailing Address - Street 1:414 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:NY
Mailing Address - Zip Code:14103-1417
Mailing Address - Country:US
Mailing Address - Phone:585-798-4930
Mailing Address - Fax:585-798-4930
Practice Address - Street 1:414 MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:NY
Practice Address - Zip Code:14103-1417
Practice Address - Country:US
Practice Address - Phone:585-798-4930
Practice Address - Fax:585-798-4930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02604873Medicaid