=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225704042
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYE & I EYECARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2021
-----------------------------------------------------
Last Update Date | 08/20/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19214 NORTHERN BLVD FL 2
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11358-2955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-279-2020
-----------------------------------------------------
Fax | 202-217-4983
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19214 NORTHERN BLVD FL 2
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11358-2955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-279-2020
-----------------------------------------------------
Fax | 202-217-4983
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | CRYSTAL HAN
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 516-728-0712
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------