Healthcare Provider Details

I. General information

NPI: 1598867418
Provider Name (Legal Business Name): MR. RICHARD CHAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

187 E 116TH ST WIZARD OF EYES
NEW YORK NY
10029-1342
US

IV. Provider business mailing address

26 PEBBLE BROOK DR
CARMEL NY
10512-4317
US

V. Phone/Fax

Practice location:
  • Phone: 212-996-7676
  • Fax:
Mailing address:
  • Phone: 845-208-3345
  • Fax: 845-208-3344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number006252
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: