1245261593 NPI number — EYELLUSION VISION CENTER INCORPORATED

Table of content: (NPI 1245261593)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245261593 NPI number — EYELLUSION VISION CENTER INCORPORATED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYELLUSION VISION CENTER INCORPORATED
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EYELLUSION VISION CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245261593
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6909 ROOSEVELT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODSIDE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11377-2933
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-639-1392
Provider Business Mailing Address Fax Number:
718-639-2041

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6909 ROOSEVELT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODSIDE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11377-2933
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-639-1392
Provider Business Practice Location Address Fax Number:
718-639-2041
Provider Enumeration Date:
07/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FERNANDEZ
Authorized Official First Name:
HERMINIO
Authorized Official Middle Name:
V
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
718-639-1392

Provider Taxonomy Codes

  • Taxonomy code: 156FX1800X , with the licence number:  006666 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02291789 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 44101 . This is a "DAVIS VISION" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 5499979 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: NY6666 . This is a "EYEMED" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 333641 . This is a "NVA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: EV14830 . This is a "SPECTERA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 205119 . This is a "COLE MANAGED" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 7186391392 . This is a "HIP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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