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General NPI Number Information
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NPI Number | 1043066624
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Entity Type | Organization
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Legal Business Name | TJ FANCY ENTERPRISES LLC
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Dates
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Enumeration Date | 04/25/2024
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Last Update Date | 04/25/2024
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Provider Practice Location Address
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Address Line | 104 KASSON RD STE C
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City | CAMILLUS
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State | NY
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Zip | 13031-2248
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Country | US
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Telephone | 315-487-0327
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Fax | 315-487-4425
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Provider Business Mailing Address
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Address Line | 104 KASSON RD STE C
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City | CAMILLUS
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State | NY
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Zip | 13031-2248
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Country | US
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Telephone | 315-487-0327
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Fax | 315-487-4425
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Authorized Official
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Title or Position | OWNER
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Name | TANYA GREVELDING
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Credential |
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Telephone | 315-418-2396
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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