Provider Demographics
NPI:1760669485
Name:KENNETH L. STACK OPTOMETRIST, PC
Entity Type:Organization
Organization Name:KENNETH L. STACK OPTOMETRIST, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:L
Authorized Official - Last Name:STACK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:518-438-6669
Mailing Address - Street 1:24 ROSEMONT ST
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-2405
Mailing Address - Country:US
Mailing Address - Phone:518-438-6669
Mailing Address - Fax:518-489-4372
Practice Address - Street 1:24 ROSEMONT ST
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-2405
Practice Address - Country:US
Practice Address - Phone:518-438-6669
Practice Address - Fax:518-489-4372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-24
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV004607-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00931291Medicaid
NY00931291Medicaid
NY0128960001Medicare NSC
26670Medicare UPIN