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General NPI Number Information
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NPI Number | 1356491930
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Entity Type | Organization
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Legal Business Name | BETHPAGE OPTICAL, LLC
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Dates
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Enumeration Date | 01/12/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 582 STEWART AVE
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City | BETHPAGE
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State | NY
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Zip | 11714-2702
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Country | US
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Telephone | 516-433-2015
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Fax | 516-433-2017
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Provider Business Mailing Address
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Address Line | 582 STEWART AVE
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City | BETHPAGE
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State | NY
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Zip | 11714-2702
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Country | US
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Telephone | 516-433-2015
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Fax | 516-433-2017
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Authorized Official
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Title or Position | OWNER OPTICIAN
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Name | MR. MICHAEL ZAVULUNOV
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Credential |
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Telephone | 516-433-2015
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number | 007319-1
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License Number State | NY
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