Healthcare Provider Details

I. General information

NPI: 1952419053
Provider Name (Legal Business Name): WIZARD OF EYES OF 116 ST INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 02/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 212-996-7676
  • Fax:
Mailing address:
  • Phone: 212-996-7676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: MR. RICHARD CHAVIS
Title or Position: PRESIDENT/ OPTICIAN
Credential:
Phone: 212-996-7676