Healthcare Provider Details

I. General information

NPI: 1124783840
Provider Name (Legal Business Name): 110 VISION LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2021
Last Update Date: 11/08/2021
Certification Date: 10/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 WALT WHITMAN RD
HUNTINGTON STATION NY
11746-4119
US

IV. Provider business mailing address

259 WALT WHITMAN RD
HUNTINGTON STATION NY
11746-4119
US

V. Phone/Fax

Practice location:
  • Phone: 631-427-7300
  • Fax:
Mailing address:
  • Phone: 631-427-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: ARSEN KHAIMOV
Title or Position: MANAGER
Credential:
Phone: 917-400-4889