Provider Demographics
NPI:1629058029
Name:SOUTHERN TIER OPTOMETRIC CENTER INC
Entity Type:Organization
Organization Name:SOUTHERN TIER OPTOMETRIC CENTER INC
Other - Org Name:COUNCIL OPTOMETRIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SAM
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROSENSWIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-372-9464
Mailing Address - Street 1:548 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-4733
Mailing Address - Country:US
Mailing Address - Phone:716-488-1147
Mailing Address - Fax:
Practice Address - Street 1:548 W 3RD ST
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-4733
Practice Address - Country:US
Practice Address - Phone:716-488-1147
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY55144AMedicare ID - Type UnspecifiedUPSTATE MEDICARE
NY019876-0008Medicare NSC