Healthcare Provider Details

I. General information

NPI: 1164919320
Provider Name (Legal Business Name): NICHOLAS ILASI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2018
Last Update Date: 04/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 SUMMIT ST
BATAVIA NY
14020-1613
US

IV. Provider business mailing address

2469 STATE ROUTE 19 N
WARSAW NY
14569-9336
US

V. Phone/Fax

Practice location:
  • Phone: 585-345-1147
  • Fax: 585-345-1187
Mailing address:
  • Phone: 585-786-8505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberC003394-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: