Healthcare Provider Details

I. General information

NPI: 1538215363
Provider Name (Legal Business Name): OPTICAL FACTORY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 11/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2090B HILLSIDE AVE
NEW HYDE PARK NY
11040-2613
US

IV. Provider business mailing address

2090B HILLSIDE AVE
NEW HYDE PARK NY
11040-2613
US

V. Phone/Fax

Practice location:
  • Phone: 516-358-4040
  • Fax: 516-358-7465
Mailing address:
  • Phone: 516-358-4040
  • Fax: 516-358-7465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name: MRS. DIANE SANTACROCE
Title or Position: SECRETARY
Credential:
Phone: 631-351-4900