=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629284880
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHEN JOSEPH BOHAC OPTHALMIC DISPENSER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3300 CHAMBERS RD
-----------------------------------------------------
City | HORSEHEADS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14845-1404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-739-5644
-----------------------------------------------------
Fax | 607-796-0080
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1037 WALKER HILL RD
-----------------------------------------------------
City | WAVERLY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14892-9601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-565-3065
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | 006972-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------