Provider Demographics
NPI:1558902171
Name:STACK, SETH
Entity Type:Individual
Prefix:
First Name:SETH
Middle Name:
Last Name:STACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HATFIELD LN STE 3
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924-6753
Mailing Address - Country:US
Mailing Address - Phone:845-294-5128
Mailing Address - Fax:845-294-1479
Practice Address - Street 1:845 STATE ROUTE 17M
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NY
Practice Address - Zip Code:10950-1606
Practice Address - Country:US
Practice Address - Phone:845-294-5128
Practice Address - Fax:845-294-1479
Is Sole Proprietor?:No
Enumeration Date:2019-10-04
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician