Provider Demographics
NPI:1558679167
Name:OPTICS OF TICONDEROGA
Entity Type:Organization
Organization Name:OPTICS OF TICONDEROGA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:TITUS
Authorized Official - Suffix:
Authorized Official - Credentials:LPO
Authorized Official - Phone:518-585-4000
Mailing Address - Street 1:89 MONTCALM ST
Mailing Address - Street 2:
Mailing Address - City:TICONDEROGA
Mailing Address - State:NY
Mailing Address - Zip Code:12883-1385
Mailing Address - Country:US
Mailing Address - Phone:518-585-4000
Mailing Address - Fax:518-585-5286
Practice Address - Street 1:89 MONTCALM ST
Practice Address - Street 2:
Practice Address - City:TICONDEROGA
Practice Address - State:NY
Practice Address - Zip Code:12883-1385
Practice Address - Country:US
Practice Address - Phone:518-585-4000
Practice Address - Fax:518-585-5286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-16
Last Update Date:2014-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008987332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03126203Medicaid