Healthcare Provider Details

I. General information

NPI: 1194094227
Provider Name (Legal Business Name): MAIN ST. OPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2011
Last Update Date: 01/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 MAIN ST
MONSEY NY
10952-3005
US

IV. Provider business mailing address

39 MAIN ST
MONSEY NY
10952-3005
US

V. Phone/Fax

Practice location:
  • Phone: 845-517-5459
  • Fax: 845-517-5460
Mailing address:
  • Phone: 845-517-5459
  • Fax: 845-517-5460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number004341-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. AVROHOM A. MANES
Title or Position: MANAGER
Credential:
Phone: 845-517-5459