Provider Demographics
NPI:1700974946
Name:SOUTH PARK OPTICAL, INC.
Entity Type:Organization
Organization Name:SOUTH PARK OPTICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:BEITER
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:716-823-6093
Mailing Address - Street 1:3861 S PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BLASDELL
Mailing Address - State:NY
Mailing Address - Zip Code:14219-1813
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3861 S PARK AVE
Practice Address - Street 2:
Practice Address - City:BLASDELL
Practice Address - State:NY
Practice Address - Zip Code:14219-1813
Practice Address - Country:US
Practice Address - Phone:716-823-6093
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC-5093-1156FX1800X
NY5093332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4512520001Medicare NSC