Basic Information
| Provider Information | |||||||||
| NPI: | 1396139838 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STRONG OPTICAL SHOP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COLLEGE TOWN OPTICAL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 ELMWOOD AVE | ||||||||
| Address2: | BOX 659 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146420001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852763273 | ||||||||
| FaxNumber: | 5852760236 | ||||||||
| Practice Location | |||||||||
| Address1: | 1317 MOUNT HOPE AVE | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146203923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852767676 | ||||||||
| FaxNumber: | 5852761493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2015 | ||||||||
| LastUpdateDate: | 09/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HETTERICH | ||||||||
| AuthorizedOfficialFirstName: | JILL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, URMC FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 5857564003 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | NY | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
No ID Information.