Healthcare Provider Details

I. General information

NPI: 1558544171
Provider Name (Legal Business Name): AFCORNELL OPTICIANS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2007
Last Update Date: 12/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ROUTE 9W FAITH PLAZA
RAVENA NY
12143
US

IV. Provider business mailing address

ROUTE 9W FAITH PLAZA
RAVENA NY
12143
US

V. Phone/Fax

Practice location:
  • Phone: 518-756-3135
  • Fax: 518-756-2258
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4607
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number004744-1
License Number StateNY

VIII. Authorized Official

Name: ANTHONY CORNELL
Title or Position: OWNER
Credential:
Phone: 518-756-3135