=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295272953
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CREIGHTON OPTICAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2017
-----------------------------------------------------
Last Update Date | 02/06/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13295 BROADWAY ST
-----------------------------------------------------
City | ALDEN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14004-1324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-937-7373
-----------------------------------------------------
Fax | 716-937-4136
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13295 BROADWAY ST
-----------------------------------------------------
City | ALDEN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14004-1324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-937-7373
-----------------------------------------------------
Fax | 716-937-4136
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. DEREK ZAKRZEWSKI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 716-937-7373
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------