Provider Demographics
NPI:1437520699
Name:OLD SARATOGA OPTOMETRY & OPHTHALMIC DISPENSING, PLLC
Entity type:Organization
Organization Name:OLD SARATOGA OPTOMETRY & OPHTHALMIC DISPENSING, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPHTHALMIC DISPENSER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TARA
Authorized Official - Middle Name:L
Authorized Official - Last Name:LAFAVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-692-2040
Mailing Address - Street 1:1224 STATE ROUTE 29
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:NY
Mailing Address - Zip Code:12834-6120
Mailing Address - Country:US
Mailing Address - Phone:518-692-2040
Mailing Address - Fax:518-692-2440
Practice Address - Street 1:1224 STATE ROUTE 29
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:NY
Practice Address - Zip Code:12834-6120
Practice Address - Country:US
Practice Address - Phone:518-692-2040
Practice Address - Fax:518-692-2440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-14
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006019332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1275720781Medicare PIN
NY1922050483Medicare PIN