=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114222866
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LULUEYEZ
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2011
-----------------------------------------------------
Last Update Date | 01/11/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 209 W ROUTE 59
-----------------------------------------------------
City | NANUET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10954-2218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-623-4166
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 209 W ROUTE 59
-----------------------------------------------------
City | NANUET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10954-2218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-623-4166
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. ANTONIO BURGOS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 845-623-4166
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------