MEDICARE: NY VISION GROUP

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	TUV008183-1	NY

General Provider Information

NPI Number	:	1326449513
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NY VISION GROUP

Provider Business Mailing Address
First Line	:	11915 ATLANTIC AVE
Second Line	:
City	:	RICHMOND HILL
State	:	NY
Zip	:	11418-3216
Country	:	US
Telephone Number	:	718-805-0700
Fax Number	:	718-805-5621

Provider Business Practice Location Address
First Line	:	11915 ATLANTIC AVE
Second Line	:
City	:	RICHMOND HILL
State	:	NY
Zip	:	11418-3216
Country	:	US
Telephone Number	:	718-805-0700
Fax Number	:	718-805-5621

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	MS. YVONNE LOPEZ
Credential	:
Telephone Number	:	718-805-0700

Provider Enumeration Date	:	09/08/2014
Last Update Date	:	09/08/2014

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