Healthcare Provider Details

I. General information

NPI: 1649333493
Provider Name (Legal Business Name): NORTHEAST SPEC CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 OLD GICK RD
WILTON NY
12866
US

IV. Provider business mailing address

PO BOX 496
DELMAR NY
12054
US

V. Phone/Fax

Practice location:
  • Phone: 518-587-0258
  • Fax: 518-583-3991
Mailing address:
  • Phone: 518-587-0258
  • Fax: 518-583-3991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT003818
License Number StateNY

VIII. Authorized Official

Name: DR. KERRY LEE HARBECK
Title or Position: PRESIDENT OD
Credential: OD
Phone: 518-587-0258