=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366592891
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARK AVENUE EYELAND INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2007
-----------------------------------------------------
Last Update Date | 11/03/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 58 W PARK AVE
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11561-2030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-670-0600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 186 BLACKHEATH RD
-----------------------------------------------------
City | LIDO BEACH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11561-4840
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-889-0401
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | DR. LELAND STANN BARRY
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 516-670-0600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | T004095
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------