Provider Demographics
NPI:1629549399
Name:UPSTATE VISION CARE, PLLC
Entity Type:Organization
Organization Name:UPSTATE VISION CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/NYS LICENSED OPTICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:L
Authorized Official - Last Name:ST.JOHN
Authorized Official - Suffix:
Authorized Official - Credentials:OPTHALMIC DISPENSER
Authorized Official - Phone:518-744-7136
Mailing Address - Street 1:206 GLEN ST. SUITE 31B
Mailing Address - Street 2:COLVIN BUILDING
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801
Mailing Address - Country:US
Mailing Address - Phone:518-744-7136
Mailing Address - Fax:
Practice Address - Street 1:206 GLEN ST. SUITE 31B
Practice Address - Street 2:COLVIN BUILDING
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801
Practice Address - Country:US
Practice Address - Phone:518-744-7136
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-06
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact LensGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1275000853OtherINDIVIDUAL