Healthcare Provider Details

I. General information

NPI: 1992096150
Provider Name (Legal Business Name): GRAND CONCOURSE BRONX EYE CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2011
Last Update Date: 11/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2376 GRAND CONCOURSE
BRONX NY
10458-6907
US

IV. Provider business mailing address

2376 GRAND CONCOURSE
BRONX NY
10458-6907
US

V. Phone/Fax

Practice location:
  • Phone: 718-365-6300
  • Fax: 718-477-6702
Mailing address:
  • Phone: 718-365-6300
  • Fax: 718-477-6702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License NumberTUV007588
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number003094
License Number StateNY

VIII. Authorized Official

Name: MS. ELAINA ZAVELENSKY
Title or Position: MGR
Credential:
Phone: 718-365-6300