Healthcare Provider Details

I. General information

NPI: 1356763056
Provider Name (Legal Business Name): COOP CITY EYE CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2014
Last Update Date: 09/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

691 CO OP CITY BLVD
BRONX NY
10475-1673
US

IV. Provider business mailing address

691 CO OP CITY BLVD
BRONX NY
10475-1673
US

V. Phone/Fax

Practice location:
  • Phone: 718-320-0551
  • Fax: 347-843-0430
Mailing address:
  • Phone: 718-320-0551
  • Fax: 347-843-0430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV007786
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberTUV007786
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number008630
License Number StateNY

VIII. Authorized Official

Name: MR. EDWARD BANGIYEV
Title or Position: OPTICIAN/OWNER
Credential: OPTHALMIC DISPENSER
Phone: 718-320-0551