Provider Demographics
NPI:1629088273
Name:LICATA OPTICAL CO. INC.
Entity Type:Organization
Organization Name:LICATA OPTICAL CO. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:S
Authorized Official - Last Name:LICATA
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:716-433-1844
Mailing Address - Street 1:5683 S TRANSIT RD
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094-5844
Mailing Address - Country:US
Mailing Address - Phone:716-433-1844
Mailing Address - Fax:716-433-1047
Practice Address - Street 1:5683 S TRANSIT RD
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-5844
Practice Address - Country:US
Practice Address - Phone:716-433-1844
Practice Address - Fax:716-433-1047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00026918201OtherUNIVERA
NY208911OtherHIMARK-CLARITY
NY00026918207OtherUNIVERA COM. HEALTH
NY00026955801OtherUNIVERA 4 FRONT
NY333691OtherNVA
NYOP-0229-01OtherEYEMED
NY000300065003OtherBLUE CROSS BLUE SHIELD
NY016180OtherBLOZK
NY7310246OtherIND. HEALTH
NYNY2497OtherVBA
NY208911OtherHIMARK-CLARITY