=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285278606
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PURE EYECARE OPTOMETRY P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2019
-----------------------------------------------------
Last Update Date | 10/29/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10537 65TH AVE APT 4D
-----------------------------------------------------
City | FOREST HILLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11375-1818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-476-7757
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10537 65TH AVE APT 4D
-----------------------------------------------------
City | FOREST HILLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11375-1818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-476-7757
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR OF OPTOMETRY
-----------------------------------------------------
Name | DR. ROMAN KAKZANOV
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 917-476-7757
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------