Healthcare Provider Details

I. General information

NPI: 1043769425
Provider Name (Legal Business Name): LA BLEU OPTIQUE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2016
Last Update Date: 09/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1156 6TH AVE
NEW YORK NY
10036-2702
US

IV. Provider business mailing address

1156 6TH AVE
NEW YORK NY
10036-2702
US

V. Phone/Fax

Practice location:
  • Phone: 646-852-6580
  • Fax:
Mailing address:
  • Phone: 646-852-6580
  • Fax:

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: MR. IGOR ABRAMOV
Title or Position: OWNER
Credential:
Phone: 646-852-6580