Healthcare Provider Details

I. General information

NPI: 1720101223
Provider Name (Legal Business Name): BONAFIDE EYEWEAR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 04/15/2022
Certification Date: 04/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6825 FRESHPOND RD
RIDGEWOOD NY
11385
US

IV. Provider business mailing address

6825 FRESHPOND ROAD
RIDGEWOOD NY
11385
US

V. Phone/Fax

Practice location:
  • Phone: 718-386-9721
  • Fax:
Mailing address:
  • Phone: 718-386-9721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number4359
License Number StateNY

VIII. Authorized Official

Name: MR. ALEX BABAYEV
Title or Position: OWNER
Credential:
Phone: 917-680-1470