Provider Demographics
NPI:1619040771
Name:PAK OPTICAL OF WATERTOWN INC
Entity Type:Organization
Organization Name:PAK OPTICAL OF WATERTOWN INC
Other - Org Name:J OPTICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:JR
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:315-782-8860
Mailing Address - Street 1:111 COURT ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-2534
Mailing Address - Country:US
Mailing Address - Phone:315-782-8860
Mailing Address - Fax:315-782-8863
Practice Address - Street 1:111 COURT ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-2534
Practice Address - Country:US
Practice Address - Phone:315-782-8860
Practice Address - Fax:315-782-8863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC003300156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0613240001Medicare ID - Type Unspecified