Provider Demographics
NPI:1811164882
Name:MAIN STREET OPTICAL
Entity type:Organization
Organization Name:MAIN STREET OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:T
Authorized Official - Last Name:KISSACK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:585-624-2122
Mailing Address - Street 1:1 N MAIN ST
Mailing Address - Street 2:549
Mailing Address - City:HONEOYE FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14472-1013
Mailing Address - Country:US
Mailing Address - Phone:585-624-2122
Mailing Address - Fax:585-624-2122
Practice Address - Street 1:1 N MAIN ST
Practice Address - Street 2:549
Practice Address - City:HONEOYE FALLS
Practice Address - State:NY
Practice Address - Zip Code:14472-1013
Practice Address - Country:US
Practice Address - Phone:585-624-2122
Practice Address - Fax:585-624-2122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004875332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY31783BMedicaid
NY8788OtherEXCELLUS BC/BS
NY100162OtherPREFERRED CARE
NY100162OtherPREFERRED CARE