Healthcare Provider Details

I. General information

NPI: 1508129693
Provider Name (Legal Business Name): EXQUISITE EYE WEAR INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2012
Last Update Date: 06/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

916 CARMANS RD
MASSAPEQUA NY
11758-3505
US

IV. Provider business mailing address

916 CARMANS RD
MASSAPEQUA NY
11758-3505
US

V. Phone/Fax

Practice location:
  • Phone: 917-617-0071
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number008978-1
License Number StateNY

VIII. Authorized Official

Name: YEFIM SAFIYEV
Title or Position: PRESIDENT
Credential:
Phone: 917-617-0071