MEDICARE: HARLEM VISTASITE EYE CARE 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	152W00000X	Optometrist

General Provider Information

NPI Number	:	1942768387
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HARLEM VISTASITE EYE CARE INC

Provider Business Mailing Address
First Line	:	2204 FREDERICK DOUGLASS BLVD
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10026-1172
Country	:	US
Telephone Number	:	917-969-4361
Fax Number	:	212-938-5831

Provider Business Practice Location Address
First Line	:	2204 FREDERICK DOUGLASS BLVD
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10026-1172
Country	:	US
Telephone Number	:	646-895-9000
Fax Number	:	646-891-0202

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. SIDNEY CONTRERAS
Credential	:
Telephone Number	:	917-969-4361

Provider Enumeration Date	:	03/05/2019
Last Update Date	:	01/24/2023

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