MEDICARE: CLAIRMONT-NICHOLS OF FIRST AVENUE INC.

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	332H00000X	Eyewear Supplier	04442	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1639355639	OTHER		NPI
2	1366634131	OTHER		NPI

General Provider Information

NPI Number	:	1639355639
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLAIRMONT-NICHOLS OF FIRST AVENUE INC.

Provider Business Mailing Address
First Line	:	1016 1ST AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10022-4107
Country	:	US
Telephone Number	:	212-758-2346
Fax Number	:	212-750-3583

Provider Business Practice Location Address
First Line	:	1016 1ST AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10022-4107
Country	:	US
Telephone Number	:	212-758-2346
Fax Number	:	212-750-3583

Authorized Official
Title or Position	:	OPTICIAN
Name	:	MR. LLOYD ANDREW MALSIN
Credential	:
Telephone Number	:	212-758-2346

Provider Enumeration Date	:	01/21/2008
Last Update Date	:	01/22/2008

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Practice Location Address:

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1346598075 — MR. DOUGLAS C WALKER IV PHARMD
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1689104655 — STEFANIE M PARKER PA
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