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General NPI Number Information
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NPI Number | 1194247619
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Entity Type | Organization
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Legal Business Name | LIBERTY EYECARE CORP
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Dates
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Enumeration Date | 07/17/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 11702 LIBERTY AVE
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City | SOUTH RICHMOND HILL
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State | NY
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Zip | 11419-1922
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Country | US
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Telephone | 718-517-9191
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Fax | 718-129-9199
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Provider Business Mailing Address
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Address Line | 11702 LIBERTY AVE
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City | SOUTH RICHMOND HILL
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State | NY
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Zip | 11419-1922
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Country | US
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Telephone | 718-517-9191
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Fax | 718-129-9199
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Authorized Official
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Title or Position | OWNER
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Name | MR. BORIS BANGIYEV
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Credential | OWNER
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Telephone | 718-517-9191
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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