Provider Demographics
NPI:1093775892
Name:WESTFIELD OPTICAL STUDIO LLC
Entity Type:Organization
Organization Name:WESTFIELD OPTICAL STUDIO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLIBERSUCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-793-2020
Mailing Address - Street 1:105 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:14787-1306
Mailing Address - Country:US
Mailing Address - Phone:716-793-2020
Mailing Address - Fax:716-793-3030
Practice Address - Street 1:105 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:NY
Practice Address - Zip Code:14787-1306
Practice Address - Country:US
Practice Address - Phone:716-793-2020
Practice Address - Fax:716-793-3030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-24
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X
NY0050451332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01103479Medicaid
NY02737337Medicaid
NYBA0775Medicare UPIN
NY5237940001Medicare NSC