Healthcare Provider Details

I. General information

NPI: 1700192580
Provider Name (Legal Business Name): EYECARE ADVANTAGE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2010
Last Update Date: 01/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 SUNRISE HWY
BAY SHORE NY
11706-6027
US

IV. Provider business mailing address

1953 GRAND AVE
NORTH BALDWIN NY
11510-2820
US

V. Phone/Fax

Practice location:
  • Phone: 631-647-8859
  • Fax:
Mailing address:
  • Phone: 631-647-8862
  • Fax: 631-647-8859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV0033655-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE VANESSA GIBSON
Title or Position: DIRECTOR
Credential:
Phone: 631-647-8859