Healthcare Provider Details

I. General information

NPI: 1487852612
Provider Name (Legal Business Name): RIVERDALE OPTOMETRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 W 231ST ST
BRONX NY
10463-5301
US

IV. Provider business mailing address

219 W 231ST ST
BRONX NY
10463-5301
US

V. Phone/Fax

Practice location:
  • Phone: 718-543-8066
  • Fax:
Mailing address:
  • Phone: 718-543-8066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number006447
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: SUSANNA VAYSTUB
Title or Position: MEMBER
Credential: O.D.
Phone: 718-543-8066