Healthcare Provider Details

I. General information

NPI: 1104227305
Provider Name (Legal Business Name): NY VISION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2014
Last Update Date: 09/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11915 ATLANTIC AVE
RICHMOND HILL NY
11418-3216
US

IV. Provider business mailing address

11915 ATLANTIC AVE
RICHMOND HILL NY
11418-3216
US

V. Phone/Fax

Practice location:
  • Phone: 718-805-0700
  • Fax: 718-805-5621
Mailing address:
  • Phone: 718-805-0700
  • Fax: 718-805-5621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV007996-1
License Number StateNY

VIII. Authorized Official

Name: MS. YVONNE LOPEZ
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 718-805-0700