Provider Demographics
NPI:1699983262
Name:OPTIVISION
Entity type:Organization
Organization Name:OPTIVISION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN,OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:W
Authorized Official - Last Name:MCNEIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-753-7514
Mailing Address - Street 1:3662 THE PARK
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-3324
Mailing Address - Country:US
Mailing Address - Phone:607-753-7514
Mailing Address - Fax:607-753-7515
Practice Address - Street 1:3662 THE PARK
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-3324
Practice Address - Country:US
Practice Address - Phone:607-753-7514
Practice Address - Fax:607-753-7515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV005032152W00000X, 332H00000X
NY4079156FX1800X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY54183AMedicare PIN
NY4815910001Medicare NSC