Provider Demographics
NPI:1851844500
Name:OPTICAL SHOP OF CLIFTON PARK LLC
Entity Type:Organization
Organization Name:OPTICAL SHOP OF CLIFTON PARK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:BRASS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-782-7827
Mailing Address - Street 1:1783 ROUTE 9
Mailing Address - Street 2:SUITE 106
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-2409
Mailing Address - Country:US
Mailing Address - Phone:518-348-2062
Mailing Address - Fax:
Practice Address - Street 1:1783 ROUTE 9
Practice Address - Street 2:SUITE 106
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-2409
Practice Address - Country:US
Practice Address - Phone:518-348-2062
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-29
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004953-1156FX1800X
NY005490-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty