Provider Demographics
NPI:1013135391
Name:ADIRONDACK OPTICAL OUTFITTERS
Entity Type:Organization
Organization Name:ADIRONDACK OPTICAL OUTFITTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-585-9922
Mailing Address - Street 1:84 MONTCALM ST # 5
Mailing Address - Street 2:
Mailing Address - City:TICONDEROGA
Mailing Address - State:NY
Mailing Address - Zip Code:12883-1361
Mailing Address - Country:US
Mailing Address - Phone:518-585-9922
Mailing Address - Fax:518-585-9927
Practice Address - Street 1:84 MONTCALM ST # 5
Practice Address - Street 2:
Practice Address - City:TICONDEROGA
Practice Address - State:NY
Practice Address - Zip Code:12883-1361
Practice Address - Country:US
Practice Address - Phone:518-585-9922
Practice Address - Fax:518-585-9927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7119152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty