Provider Demographics
NPI:1053335695
Name:FAMILY VISION CARE OPHTHALMIC DISPENSING LLC
Entity type:Organization
Organization Name:FAMILY VISION CARE OPHTHALMIC DISPENSING LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:HALSTEAD
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC, FNAO
Authorized Official - Phone:518-584-6111
Mailing Address - Street 1:205 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-2628
Mailing Address - Country:US
Mailing Address - Phone:518-584-6111
Mailing Address - Fax:518-580-8589
Practice Address - Street 1:205 LAKE AVE
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-2628
Practice Address - Country:US
Practice Address - Phone:518-584-6111
Practice Address - Fax:518-580-8589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYAA1165Medicare ID - Type UnspecifiedPRACTICE ID NUMBER
NY5359910001Medicare NSC