Provider Demographics
NPI:1164424875
Name:SOUTHERN TIER OPTOMETRIC CENTER, INC.
Entity Type:Organization
Organization Name:SOUTHERN TIER OPTOMETRIC CENTER, INC.
Other - Org Name:COUNCIL OPTOMETRIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSENSWIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-372-9464
Mailing Address - Street 1:168 N UNION ST
Mailing Address - Street 2:
Mailing Address - City:OLEAN
Mailing Address - State:NY
Mailing Address - Zip Code:14760-2735
Mailing Address - Country:US
Mailing Address - Phone:716-372-9464
Mailing Address - Fax:
Practice Address - Street 1:168 N UNION ST
Practice Address - Street 2:
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760-2735
Practice Address - Country:US
Practice Address - Phone:716-372-9464
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-12
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV002749-1152W00000X
NYC003108-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
053811Medicare PIN
NY0198760003Medicare NSC
NYCF7118Medicare PIN