Healthcare Provider Details

I. General information

NPI: 1568481752
Provider Name (Legal Business Name): GREAT NORTHERN OPTICAL EQUIPMENT INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 10/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7903 BREWERTON RD WEST MARINE PLAZA
CICERO NY
13039-9531
US

IV. Provider business mailing address

7903 BREWERTON RD WEST MARINE PLAZA
CICERO NY
13039-9531
US

V. Phone/Fax

Practice location:
  • Phone: 315-699-1700
  • Fax: 315-699-1700
Mailing address:
  • Phone: 315-699-1700
  • Fax: 315-699-1700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV003420-1
License Number StateNY

VIII. Authorized Official

Name: DR. CARL FRANCIS AZZOTO
Title or Position: OPTOMETRIST
Credential: OD
Phone: 315-622-4607