Healthcare Provider Details

I. General information

NPI: 1801323209
Provider Name (Legal Business Name): MILLENIA VISION CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

469 W 125TH ST
NEW YORK NY
10027-4201
US

IV. Provider business mailing address

469 W 125TH ST
NEW YORK NY
10027-4201
US

V. Phone/Fax

Practice location:
  • Phone: 646-767-1951
  • Fax:
Mailing address:
  • Phone: 646-767-1951
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV008217
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: NATHAN YAKUBOV
Title or Position: OWNER
Credential:
Phone: 646-767-1951