=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609099563
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CREIGHTON OPTICAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2007
-----------------------------------------------------
Last Update Date | 02/14/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13375 BROADWAY ST
-----------------------------------------------------
City | ALDEN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14004-1410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-937-7373
-----------------------------------------------------
Fax | 716-937-4136
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13375 BROADWAY ST
-----------------------------------------------------
City | ALDEN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14004-1410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-937-7373
-----------------------------------------------------
Fax | 716-937-4136
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTICIAN OWNER
-----------------------------------------------------
Name | MR. JAMES F CREIGHTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 716-937-7373
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | 2738
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | 6357
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 3610
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | V0048731
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | UT003462
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------