Healthcare Provider Details

I. General information

NPI: 1316094147
Provider Name (Legal Business Name): WAGNER OPTICAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 10/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 BROADWAY
BUFFALO NY
14212-1218
US

IV. Provider business mailing address

945 BROADWAY
BUFFALO NY
14212-1218
US

V. Phone/Fax

Practice location:
  • Phone: 716-845-6080
  • Fax: 716-845-0167
Mailing address:
  • Phone: 716-845-6080
  • Fax: 716-845-0167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. RICHARD JAMES WITT
Title or Position: PRESIDENT
Credential: OPTICIAN
Phone: 716-845-6080