Healthcare Provider Details

I. General information

NPI: 1033456140
Provider Name (Legal Business Name): BRILLIANT VISION CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2013
Last Update Date: 08/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

97-21 QUEENS BLVD
REGO PARK NY
11374
US

IV. Provider business mailing address

97-21 QUEENS BLVD
REGO PARK NY
11374
US

V. Phone/Fax

Practice location:
  • Phone: 347-840-3244
  • Fax:
Mailing address:
  • Phone: 347-840-3244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ELEANORA MULLOKANDOVA
Title or Position: OPTICIAN
Credential:
Phone: 347-840-3244