Healthcare Provider Details

I. General information

NPI: 1609099563
Provider Name (Legal Business Name): CREIGHTON OPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 02/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13375 BROADWAY ST
ALDEN NY
14004-1410
US

IV. Provider business mailing address

13375 BROADWAY ST
ALDEN NY
14004-1410
US

V. Phone/Fax

Practice location:
  • Phone: 716-937-7373
  • Fax: 716-937-4136
Mailing address:
  • Phone: 716-937-7373
  • Fax: 716-937-4136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberUT003462
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberV0048731
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3610
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number2738
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number6357
License Number StateNY

VIII. Authorized Official

Name: MR. JAMES F CREIGHTON
Title or Position: OPTICIAN OWNER
Credential:
Phone: 716-937-7373