=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043543192
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDICAL EYE GLASS CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2009
-----------------------------------------------------
Last Update Date | 09/08/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2604 3RD AVE
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10454-1117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-522-3115
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 234 BROAD ST
-----------------------------------------------------
City | SUMMIT
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07901-3574
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-522-3115
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ROBERT KATZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 908-522-3115
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------