Provider Demographics
NPI:1831339639
Name:HALL OPTICAL
Entity type:Organization
Organization Name:HALL OPTICAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:H
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:716-483-1955
Mailing Address - Street 1:707 FAIRMOUNT AVE
Mailing Address - Street 2:SUITE 11
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-2623
Mailing Address - Country:US
Mailing Address - Phone:716-483-1955
Mailing Address - Fax:
Practice Address - Street 1:707 FAIRMOUNT AVE
Practice Address - Street 2:SUITE 11
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-2623
Practice Address - Country:US
Practice Address - Phone:716-483-1955
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-06
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4127-1332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00622211Medicaid
NY1831339639Medicare PIN