Provider Demographics
NPI:1770761686
Name:KNAUF OPTICAL
Entity type:Organization
Organization Name:KNAUF OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:AVERY
Authorized Official - Suffix:SR
Authorized Official - Credentials:LICENSED OPTICIAN
Authorized Official - Phone:607-748-0765
Mailing Address - Street 1:235 VESTAL AVE
Mailing Address - Street 2:
Mailing Address - City:ENDICOTT
Mailing Address - State:NY
Mailing Address - Zip Code:13760-4928
Mailing Address - Country:US
Mailing Address - Phone:607-748-0765
Mailing Address - Fax:607-748-0765
Practice Address - Street 1:235 VESTAL AVE
Practice Address - Street 2:
Practice Address - City:ENDICOTT
Practice Address - State:NY
Practice Address - Zip Code:13760-4928
Practice Address - Country:US
Practice Address - Phone:607-748-0765
Practice Address - Fax:607-748-0765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-01
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY6965332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNY6965OtherEYEMED
NY7579607OtherAETNA
NY4853080001Medicare NSC