Provider Demographics
NPI:1275717852
Name:LYNN R HENRY OPTOMETRIST PC
Entity Type:Organization
Organization Name:LYNN R HENRY OPTOMETRIST PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:R
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:315-894-3325
Mailing Address - Street 1:23 CENTRAL PLZ
Mailing Address - Street 2:
Mailing Address - City:ILION
Mailing Address - State:NY
Mailing Address - Zip Code:13357-1701
Mailing Address - Country:US
Mailing Address - Phone:315-894-3325
Mailing Address - Fax:
Practice Address - Street 1:23 CENTRAL PLZ
Practice Address - Street 2:
Practice Address - City:ILION
Practice Address - State:NY
Practice Address - Zip Code:13357-1701
Practice Address - Country:US
Practice Address - Phone:315-894-3325
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV003458-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY32491BMedicare PIN
SC0179070001Medicare NSC
NYT26382Medicare UPIN