Provider Demographics
NPI:1760990139
Name:MANN, LONNIE G (NYS LICENSED OPTICIA)
Entity Type:Individual
Prefix:MR
First Name:LONNIE
Middle Name:G
Last Name:MANN
Suffix:
Gender:M
Credentials:NYS LICENSED OPTICIA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3275 BROCKPORT SPENCERPORT RD
Mailing Address - Street 2:
Mailing Address - City:SPENCERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14559-2167
Mailing Address - Country:US
Mailing Address - Phone:585-305-8644
Mailing Address - Fax:
Practice Address - Street 1:3275 BROCKPORT SPENCERPORT RD
Practice Address - Street 2:
Practice Address - City:SPENCERPORT
Practice Address - State:NY
Practice Address - Zip Code:14559-2167
Practice Address - Country:US
Practice Address - Phone:585-305-8644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-18
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010116332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier