=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235538596
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIBERTY OPTICAL CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2014
-----------------------------------------------------
Last Update Date | 08/22/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12102 LIBERTY AVE
-----------------------------------------------------
City | SOUTH RICHMOND HILL
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11419-2112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-835-3400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12102 LIBERTY AVE
-----------------------------------------------------
City | SOUTH RICHMOND HILL
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11419-2112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-835-3400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. MARK BARAYEV
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-835-3400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | TUV007786
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------