Provider Demographics
NPI:1023168325
Name:CONRAD W. KASACK, INC
Entity type:Organization
Organization Name:CONRAD W. KASACK, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DOMINICK
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:VOLPE
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:203-743-3826
Mailing Address - Street 1:16 WEST ST
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-7841
Mailing Address - Country:US
Mailing Address - Phone:203-743-3826
Mailing Address - Fax:
Practice Address - Street 1:16 WEST ST
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-7841
Practice Address - Country:US
Practice Address - Phone:203-743-3826
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001268156FX1800X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004049086Medicaid
CT0312660001Medicare NSC