=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114223377
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHEAPER PEEPERS OF NEW YORK MDIV, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2011
-----------------------------------------------------
Last Update Date | 04/18/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5150 COOLIDGE HWY
-----------------------------------------------------
City | ROYAL OAK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48073-1001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-435-4200
-----------------------------------------------------
Fax | 248-288-2124
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 203 NEWBRIDGE RD
-----------------------------------------------------
City | HITCKSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11801-3933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-719-7554
-----------------------------------------------------
Fax | 248-719-7564
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGED CARE MANAGER
-----------------------------------------------------
Name | MRS. ANA MANSUY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 248-719-7554
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332G00000X
-----------------------------------------------------
Taxonomy Name | Eye Bank
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------