Healthcare Provider Details

I. General information

NPI: 1972266310
Provider Name (Legal Business Name): EYE DANCE AND SCREEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2021
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1218 ARSENAL ST
WATERTOWN NY
13601-2214
US

IV. Provider business mailing address

1218 ARSENAL ST
WATERTOWN NY
13601-2214
US

V. Phone/Fax

Practice location:
  • Phone: 315-755-6348
  • Fax:
Mailing address:
  • Phone: 315-755-6348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateNULL

VIII. Authorized Official

Name: DORIS PRASHAW
Title or Position: MANAGER
Credential: OPTICIAN
Phone: 315-755-6348