=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366777377
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOOKS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2009
-----------------------------------------------------
Last Update Date | 10/08/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 295 GREENWICH ST
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10007-1049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-608-2150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 295 GREENWICH ST
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10007-1049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-608-2150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTICIAN
-----------------------------------------------------
Name | MR. VITALY GUMENIK
-----------------------------------------------------
Credential | OPTICIAN
-----------------------------------------------------
Telephone | 212-608-2150
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | 008166-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------