Healthcare Provider Details

I. General information

NPI: 1376095992
Provider Name (Legal Business Name): RALPH PLACE OPTICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2016
Last Update Date: 10/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 RALPH PL SUITE 101
STATEN ISLAND NY
10304-4401
US

IV. Provider business mailing address

8 RIDGEWAY DR
KINGS POINT NY
11024-1435
US

V. Phone/Fax

Practice location:
  • Phone: 718-720-2001
  • Fax:
Mailing address:
  • Phone: 718-720-2001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV004573
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number191296
License Number StateNY

VIII. Authorized Official

Name: FARZAD FAKHERI
Title or Position: PRESIDENT
Credential: MD
Phone: 718-720-2001