MEDICARE: MAIN STREET OPTICAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332H00000X	Eyewear Supplier	004875	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	8788	OTHER	NY	EXCELLUS BC/BS
3	100162	OTHER	NY	PREFERRED CARE

General Provider Information

NPI Number	:	1811164882
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAIN STREET OPTICAL

Provider Business Mailing Address
First Line	:	1 N MAIN ST
Second Line	:	549
City	:	HONEOYE FALLS
State	:	NY
Zip	:	14472-1013
Country	:	US
Telephone Number	:	585-624-2122
Fax Number	:	585-624-2122

Provider Business Practice Location Address
First Line	:	1 N MAIN ST
Second Line	:	549
City	:	HONEOYE FALLS
State	:	NY
Zip	:	14472-1013
Country	:	US
Telephone Number	:	585-624-2122
Fax Number	:	585-624-2122

Authorized Official
Title or Position	:	OWNER
Name	:	DR. BARRY T KISSACK
Credential	:	O.D.
Telephone Number	:	585-624-2122

Provider Enumeration Date	:	05/09/2008
Last Update Date	:	05/09/2008

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Directions to “MAIN STREET OPTICAL ” Practice Location

Language	Start Address	Practice Location

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