Provider Demographics
NPI:1669590519
Name:NORTH COUNTRY EYE ASSOC..LLC
Entity type:Organization
Organization Name:NORTH COUNTRY EYE ASSOC..LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:M
Authorized Official - Last Name:BULAS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:315-896-3900
Mailing Address - Street 1:8024 RT 12
Mailing Address - Street 2:
Mailing Address - City:BARNEVELD
Mailing Address - State:NY
Mailing Address - Zip Code:13304
Mailing Address - Country:US
Mailing Address - Phone:315-896-3900
Mailing Address - Fax:315-896-3905
Practice Address - Street 1:8024 STATE ROUTE 12
Practice Address - Street 2:
Practice Address - City:BARNEVELD
Practice Address - State:NY
Practice Address - Zip Code:13304
Practice Address - Country:US
Practice Address - Phone:315-896-3900
Practice Address - Fax:315-896-3905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV0048421152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1251740001Medicare NSC
BA1139Medicare PIN