Healthcare Provider Details

I. General information

NPI: 1982105037
Provider Name (Legal Business Name): MICHELLE NIEMIEC OPTICIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2018
Last Update Date: 09/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1097 ROUTE 55 STE 4
LAGRANGEVILLE NY
12540-5027
US

IV. Provider business mailing address

1097 ROUTE 55 STE 4
LAGRANGEVILLE NY
12540-5027
US

V. Phone/Fax

Practice location:
  • Phone: 845-471-7710
  • Fax: 845-471-7746
Mailing address:
  • Phone: 845-471-7710
  • Fax: 845-471-7746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number010085
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: