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General NPI Number Information
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NPI Number | 1811164882
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Entity Type | Organization
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Legal Business Name | MAIN STREET OPTICAL
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Dates
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Enumeration Date | 05/09/2008
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Last Update Date | 05/09/2008
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Provider Practice Location Address
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Address Line | 1 N MAIN ST 549
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City | HONEOYE FALLS
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State | NY
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Zip | 14472-1013
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Country | US
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Telephone | 585-624-2122
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Fax | 585-624-2122
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Provider Business Mailing Address
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Address Line | 1 N MAIN ST 549
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City | HONEOYE FALLS
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State | NY
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Zip | 14472-1013
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Country | US
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Telephone | 585-624-2122
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Fax | 585-624-2122
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Authorized Official
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Title or Position | OWNER
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Name | DR. BARRY T KISSACK
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Credential | O.D.
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Telephone | 585-624-2122
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | 004875
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License Number State | NY
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