1417092313 NPI number — MY OPTICIAN NYC CORP

Table of content: (NPI 1417092313)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417092313 NPI number — MY OPTICIAN NYC CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MY OPTICIAN NYC CORP
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:
Provider Other Organization Name Type Code:
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:
1417092313
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5227 BROADWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRONX
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10463
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
212-693-1111
Provider Business Mailing Address Fax Number:
212-693-1114

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5227 BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10463-7636
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-693-1111
Provider Business Practice Location Address Fax Number:
212-693-1114
Provider Enumeration Date:
02/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SHLIMOV
Authorized Official First Name:
MARAT
Authorized Official Middle Name:
Authorized Official Title or Position:
OPTICIAN
Authorized Official Telephone Number:
212-693-1111

Provider Taxonomy Codes

  • Taxonomy code: 156FX1800X , with the licence number:  007320 , 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: 02622966 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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