Provider Demographics
NPI:1023149085
Name:ELMA VILLAGE OPTICAL
Entity type:Organization
Organization Name:ELMA VILLAGE OPTICAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:O'CONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-652-1776
Mailing Address - Street 1:2355 BOWEN ROAD
Mailing Address - Street 2:P O BOX 105
Mailing Address - City:ELMA
Mailing Address - State:NY
Mailing Address - Zip Code:14059-0105
Mailing Address - Country:US
Mailing Address - Phone:716-652-1776
Mailing Address - Fax:716-652-1776
Practice Address - Street 1:2355 BOWEN ROAD
Practice Address - Street 2:
Practice Address - City:ELMA
Practice Address - State:NY
Practice Address - Zip Code:14059-0105
Practice Address - Country:US
Practice Address - Phone:716-652-1776
Practice Address - Fax:716-652-1776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Not Answered156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty