Healthcare Provider Details

I. General information

NPI: 1467407833
Provider Name (Legal Business Name): ALBANY REGIONAL EYE SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 11/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 JOHNSON RD
LATHAM NY
12110-3003
US

IV. Provider business mailing address

5 JOHNSON RD
LATHAM NY
12110-3003
US

V. Phone/Fax

Practice location:
  • Phone: 518-782-1181
  • Fax:
Mailing address:
  • Phone: 518-782-1181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number0153204R
License Number StateNY

VIII. Authorized Official

Name: GLENN DE BRUEYS
Title or Position: ADMINISTRATOR
Credential:
Phone: 518-782-1181