Healthcare Provider Details

I. General information

NPI: 1407185283
Provider Name (Legal Business Name): ROYAL OPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2009
Last Update Date: 12/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

328 W 125TH ST
NEW YORK NY
10027-3641
US

IV. Provider business mailing address

328 W 125TH ST
NEW YORK NY
10027-3641
US

V. Phone/Fax

Practice location:
  • Phone: 212-663-2020
  • Fax:
Mailing address:
  • Phone: 212-663-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number008630
License Number StateNY

VIII. Authorized Official

Name: EDWARD BANGIYEV
Title or Position: OWNER/OPTICIAN
Credential:
Phone: 347-475-6692