Healthcare Provider Details

I. General information

NPI: 1609436542
Provider Name (Legal Business Name): WHOLE PICTURE HEALTH AND VISION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2019
Last Update Date: 06/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 N AURORA ST
ITHACA NY
14850-4202
US

IV. Provider business mailing address

322 N AURORA ST
ITHACA NY
14850-4202
US

V. Phone/Fax

Practice location:
  • Phone: 607-277-4749
  • Fax: 607-277-5216
Mailing address:
  • Phone: 607-277-4749
  • Fax: 607-277-5216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: TANYA S BLOOM
Title or Position: OWNER
Credential: OD
Phone: 607-277-4749