MEDICARE: LIBERTY EYECARE CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist

General Provider Information

NPI Number	:	1194247619
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIBERTY EYECARE CORP

Provider Business Mailing Address
First Line	:	11702 LIBERTY AVE
Second Line	:
City	:	SOUTH RICHMOND HILL
State	:	NY
Zip	:	11419-1922
Country	:	US
Telephone Number	:	718-517-9191
Fax Number	:	718-129-9199

Provider Business Practice Location Address
First Line	:	11702 LIBERTY AVE
Second Line	:
City	:	SOUTH RICHMOND HILL
State	:	NY
Zip	:	11419-1922
Country	:	US
Telephone Number	:	718-517-9191
Fax Number	:	718-129-9199

Authorized Official
Title or Position	:	OWNER
Name	:	MR. BORIS BANGIYEV
Credential	:	OWNER
Telephone Number	:	718-517-9191

Provider Enumeration Date	:	07/17/2017
Last Update Date	:	07/21/2022

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