Provider Demographics
NPI:1184723868
Name:SOUTHERN TIER ASSN F/T VISUALLY IMPAIRED INC
Entity type:Organization
Organization Name:SOUTHERN TIER ASSN F/T VISUALLY IMPAIRED INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:K
Authorized Official - Last Name:HERTLEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-734-1554
Mailing Address - Street 1:719 LAKE STREET
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901
Mailing Address - Country:US
Mailing Address - Phone:607-734-1554
Mailing Address - Fax:907-734-9467
Practice Address - Street 1:719 LAKE STREET
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901
Practice Address - Country:US
Practice Address - Phone:607-734-1554
Practice Address - Fax:907-734-9467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY53450AMedicare ID - Type Unspecified