Provider Demographics
NPI:1851533111
Name:RODABAUGH OPTICAL
Entity Type:Organization
Organization Name:RODABAUGH OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:T
Authorized Official - Last Name:RODABAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-739-9121
Mailing Address - Street 1:126 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HORSEHEADS
Mailing Address - State:NY
Mailing Address - Zip Code:14845-2443
Mailing Address - Country:US
Mailing Address - Phone:607-739-9121
Mailing Address - Fax:
Practice Address - Street 1:126 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HORSEHEADS
Practice Address - State:NY
Practice Address - Zip Code:14845-2443
Practice Address - Country:US
Practice Address - Phone:607-739-9121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X
NY005967156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty