Provider Demographics
NPI:1467679332
Name:LIBERTY OPTICAL GALLERY INC
Entity Type:Organization
Organization Name:LIBERTY OPTICAL GALLERY INC
Other - Org Name:OPTICAL GALLERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:NUGENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-292-3160
Mailing Address - Street 1:1949 STATE ROUTE 52
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:NY
Mailing Address - Zip Code:12754-8313
Mailing Address - Country:US
Mailing Address - Phone:845-292-3160
Mailing Address - Fax:845-292-3395
Practice Address - Street 1:1949 STATE ROUTE 52
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NY
Practice Address - Zip Code:12754-8313
Practice Address - Country:US
Practice Address - Phone:845-292-3160
Practice Address - Fax:845-292-3395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006842156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCBWQMIMedicare UPIN
NY0125890001Medicare NSC