Healthcare Provider Details

I. General information

NPI: 1144392549
Provider Name (Legal Business Name): BUENA VISTA VISION CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 10/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3777 BROADWAY
NEW YORK NY
10032-1541
US

IV. Provider business mailing address

3777 BROADWAY
NEW YORK NY
10032-1541
US

V. Phone/Fax

Practice location:
  • Phone: 212-926-0336
  • Fax: 212-926-0212
Mailing address:
  • Phone: 212-926-0336
  • Fax: 212-926-0212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV005619
License Number StateNY

VIII. Authorized Official

Name: CARLOS ALBERTO DE LA ROSA
Title or Position: PRESIDENT
Credential: OD
Phone: 212-926-0336