=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023134541
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIDE OPTICAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150 WILLIAM ST
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10038-2603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-227-9893
-----------------------------------------------------
Fax | 212-571-6397
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 150 WILLIAM ST
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10038-2603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-227-9893
-----------------------------------------------------
Fax | 212-571-6397
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRES.
-----------------------------------------------------
Name | MRS. PATRICIA LEMIS-KIM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 212-227-9893
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | TUV007100-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------