Healthcare Provider Details

I. General information

NPI: 1386033868
Provider Name (Legal Business Name): VICTORY VISION CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2015
Last Update Date: 01/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

565 ATLANTIC AVE
BROOKLYN NY
11217-1913
US

IV. Provider business mailing address

565 ATLANTIC AVE
BROOKLYN NY
11217-1913
US

V. Phone/Fax

Practice location:
  • Phone: 718-915-0791
  • Fax: 718-622-5404
Mailing address:
  • Phone: 718-915-0791
  • Fax: 718-622-5404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156FC0801X
TaxonomyContact Lens Fitter
License Number008816
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number008716
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number008816
License Number StateNY

VIII. Authorized Official

Name: VIKTOR KOLESNYK
Title or Position: VICE PRESIDENT
Credential:
Phone: 718-915-0791