Provider Demographics
NPI:1265649958
Name:DEBORILA, INC
Entity Type:Organization
Organization Name:DEBORILA, INC
Other - Org Name:LEAHY OPTICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:STONE
Authorized Official - Suffix:
Authorized Official - Credentials:OPHTHALMIC DISPENSER
Authorized Official - Phone:631-283-4244
Mailing Address - Street 1:145 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11968-4810
Mailing Address - Country:US
Mailing Address - Phone:631-283-4244
Mailing Address - Fax:631-283-4328
Practice Address - Street 1:145 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-4810
Practice Address - Country:US
Practice Address - Phone:631-283-4244
Practice Address - Fax:631-283-4328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1239420001Medicare ID - Type UnspecifiedPROVIDER NUMBER