Provider Demographics
NPI:1659468031
Name:W FRED WABY OPTICIANS INC
Entity Type:Organization
Organization Name:W FRED WABY OPTICIANS INC
Other - Org Name:WABY 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:H
Authorized Official - Last Name:CHURCHILL
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:315-593-3193
Mailing Address - Street 1:PO BOX 488
Mailing Address - Street 2:312 DIVISION STREET
Mailing Address - City:FULTON
Mailing Address - State:NY
Mailing Address - Zip Code:13069
Mailing Address - Country:US
Mailing Address - Phone:315-593-3193
Mailing Address - Fax:315-593-3199
Practice Address - Street 1:312 DIVISION STREET
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069
Practice Address - Country:US
Practice Address - Phone:315-593-3193
Practice Address - Fax:315-593-3199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY 3725156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0707370001Medicare ID - Type Unspecified