Healthcare Provider Details

I. General information

NPI: 1376908095
Provider Name (Legal Business Name): BLACKMER FAMILY EYEWEAR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2015
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4609 W GENESEE ST
SYRACUSE NY
13219-1733
US

IV. Provider business mailing address

4609 W GENESEE ST
SYRACUSE NY
13219-1733
US

V. Phone/Fax

Practice location:
  • Phone: 315-345-8004
  • Fax: 315-295-2617
Mailing address:
  • Phone: 315-345-8004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number55 006556
License Number StateNY

VIII. Authorized Official

Name: MR. HAN SONG BLACKMER
Title or Position: LICENSED OPTICIAN/OWNER
Credential:
Phone: 315-857-5402