Provider Demographics
NPI:1679645238
Name:SOUTH COUNTRY OPTICIANS INC
Entity type:Organization
Organization Name:SOUTH COUNTRY OPTICIANS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER VP SEC
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:LEONARD
Authorized Official - Last Name:RZEMIENIEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:OPHTHALMIC DISPENSER
Authorized Official - Phone:631-758-4466
Mailing Address - Street 1:331 E MAIN ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-3114
Mailing Address - Country:US
Mailing Address - Phone:631-758-4466
Mailing Address - Fax:631-758-4467
Practice Address - Street 1:331 E MAIN ST
Practice Address - Street 2:SUITE 3
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-3114
Practice Address - Country:US
Practice Address - Phone:631-758-4466
Practice Address - Fax:631-758-4467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003345156FX1800X
NY004170156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00986865Medicaid
NY00986865Medicaid