Healthcare Provider Details

I. General information

NPI: 1467841718
Provider Name (Legal Business Name): WYNN OPTICS II CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2015
Last Update Date: 05/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

629 MALCOLM X BLVD
NEW YORK NY
10037-1231
US

IV. Provider business mailing address

629 MALCOLM X BLVD
NEW YORK NY
10037-1231
US

V. Phone/Fax

Practice location:
  • Phone: 212-491-1500
  • Fax: 212-491-1509
Mailing address:
  • Phone: 212-491-1500
  • Fax: 212-491-1509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number007388
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: BERNICE SANDOVAL
Title or Position: OWNER
Credential:
Phone: 212-491-1500