Provider Demographics
NPI:1740467851
Name:ELLICOTTVILLE OPTICAL INC.
Entity type:Organization
Organization Name:ELLICOTTVILLE OPTICAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROSS
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSCATO
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:716-699-5293
Mailing Address - Street 1:PO BOX 1340
Mailing Address - Street 2:2 HUGHEY ALLEY
Mailing Address - City:ELLICOTTVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14731-1340
Mailing Address - Country:US
Mailing Address - Phone:716-699-5293
Mailing Address - Fax:716-699-8726
Practice Address - Street 1:2 HUGHEY ALLEY
Practice Address - Street 2:
Practice Address - City:ELLICOTTVILLE
Practice Address - State:NY
Practice Address - Zip Code:14731-1340
Practice Address - Country:US
Practice Address - Phone:716-699-5293
Practice Address - Fax:716-699-8726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC004448332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0814150001Medicare NSC