Healthcare Provider Details

I. General information

NPI: 1578742797
Provider Name (Legal Business Name): PLAZA OPTICAL OF MONROE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2007
Last Update Date: 10/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 STATE ROUTE 17M PLAZA OPTICAL
MONROE NY
10950-4169
US

IV. Provider business mailing address

475 STATE ROUTE 17M PLAZA OPTICAL
MONROE NY
10950-4169
US

V. Phone/Fax

Practice location:
  • Phone: 845-783-4400
  • Fax: 845-782-4041
Mailing address:
  • Phone: 845-783-4400
  • Fax: 845-782-4041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberUT5263
License Number StateNY

VIII. Authorized Official

Name: MRS. BETSY UTNICK
Title or Position: MANAGER
Credential: OPHTHALMIC DISTPENSE
Phone: 845-783-4400