=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255404315
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PAK OPTICAL OF WATERTOWN INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 MAIN STREET
-----------------------------------------------------
City | OGDENSBURG
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13669-1116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-393-7754
-----------------------------------------------------
Fax | 315-782-8863
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 COURT STREET
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13601-2534
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-782-8860
-----------------------------------------------------
Fax | 315-782-8863
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. JOHN ANTHONY KENNEDY JR.
-----------------------------------------------------
Credential | OPTICIAN NYS LICENSE
-----------------------------------------------------
Telephone | 315-782-8860
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | C4952
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------