1578773081 NPI number — FOURTH AVENUE VISION CENTER

Table of content: (NPI 1578773081)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578773081 NPI number — FOURTH AVENUE VISION CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOURTH AVENUE VISION CENTER
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:
6
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:
1578773081
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/04/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
55 S 4TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MT VERNON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10550-3104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-664-4600
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
55 S. FOURTH AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MT. VERNON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10550-3104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
914-664-4600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LUCADAMO
Authorized Official First Name:
CLAIRE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
914-664-4600

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  002488 , 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: 02902789 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com