Provider Demographics
NPI:1780867044
Name:JAN K. LIBERATORE
Entity Type:Organization
Organization Name:JAN K. LIBERATORE
Other - Org Name:J. K. LIBERATORE OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:LIBERATORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-739-0325
Mailing Address - Street 1:2751 WESTINGHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:HORSEHEADS
Mailing Address - State:NY
Mailing Address - Zip Code:14845-8100
Mailing Address - Country:US
Mailing Address - Phone:607-739-0325
Mailing Address - Fax:
Practice Address - Street 1:2751 WESTINGHOUSE RD
Practice Address - Street 2:
Practice Address - City:HORSEHEADS
Practice Address - State:NY
Practice Address - Zip Code:14845-8100
Practice Address - Country:US
Practice Address - Phone:607-739-0325
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
0643720001Medicare NSC