Healthcare Provider Details

I. General information

NPI: 1164424875
Provider Name (Legal Business Name): SOUTHERN TIER OPTOMETRIC CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 04/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

168 N UNION ST
OLEAN NY
14760-2735
US

IV. Provider business mailing address

168 N UNION ST
OLEAN NY
14760-2735
US

V. Phone/Fax

Practice location:
  • Phone: 716-372-9464
  • Fax:
Mailing address:
  • Phone: 716-372-9464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV002749-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberC003108-1
License Number StateNY

VIII. Authorized Official

Name: MRS. SAM ROSENSWIE
Title or Position: CORPORATE BUSINESS MANAGER
Credential:
Phone: 716-372-9464