Healthcare Provider Details

I. General information

NPI: 1316125594
Provider Name (Legal Business Name): BH OPTICAL OF QUEENS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2008
Last Update Date: 03/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4309 GREENPOINT AVENUE
SUNNYSIDE NY
11104-3004
US

IV. Provider business mailing address

4309 GREENPOINT AVENUE
SUNNYSIDE NY
11104-2605
US

V. Phone/Fax

Practice location:
  • Phone: 718-391-0003
  • Fax: 718-391-0003
Mailing address:
  • Phone: 718-391-0003
  • Fax: 718-391-0003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT-003792
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number008747-1
License Number StateNY

VIII. Authorized Official

Name: ROBERT USTAYEV
Title or Position: PRESIDENT
Credential: OPT
Phone: 718-391-0003