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General NPI Number Information
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NPI Number | 1710731104
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Entity Type | Organization
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Legal Business Name | EVERGREEN OPTOMETRY PLLC
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Dates
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Enumeration Date | 04/12/2024
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Last Update Date | 05/30/2024
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Provider Practice Location Address
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Address Line | 17 LONG AVE STE 102
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City | HAMBURG
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State | NY
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Zip | 14075-6200
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Country | US
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Telephone | 716-831-2717
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Fax | 716-831-2718
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Provider Business Mailing Address
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Address Line | 4845 TRANSIT RD APT B7
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City | DEPEW
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State | NY
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Zip | 14043-4717
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Country | US
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Telephone | 716-831-2717
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Fax |
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. MACKENZIE ANNE BRADLEY
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Credential | OD
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Telephone | 716-831-2717
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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