Provider Demographics
NPI:1073790002
Name:FULTON OPTICAL CORP
Entity Type:Organization
Organization Name:FULTON OPTICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:BRUMAGHIM
Authorized Official - Suffix:
Authorized Official - Credentials:OPTITIAN
Authorized Official - Phone:518-725-3513
Mailing Address - Street 1:189 SECOND AVE
Mailing Address - Street 2:
Mailing Address - City:GLOVERSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12078-2510
Mailing Address - Country:US
Mailing Address - Phone:518-725-3513
Mailing Address - Fax:518-725-3030
Practice Address - Street 1:189 SECOND AVE
Practice Address - Street 2:
Practice Address - City:GLOVERSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12078-2510
Practice Address - Country:US
Practice Address - Phone:518-725-3513
Practice Address - Fax:518-725-3030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008209332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0820170001Medicare NSC