=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619066461
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BINGHAMTON OPTICAL INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2006
-----------------------------------------------------
Last Update Date | 02/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 421 E MAIN ST
-----------------------------------------------------
City | ENDICOTT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13760
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-754-5726
-----------------------------------------------------
Fax | 607-754-5727
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 421 E MAIN ST
-----------------------------------------------------
City | ENDICOTT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13760
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-754-5726
-----------------------------------------------------
Fax | 607-754-5727
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. KEVIN P WHITING
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 607-723-8357
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 007215
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------