=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437575081
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNIMED OPTICAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2014
-----------------------------------------------------
Last Update Date | 03/06/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 175 MARCY AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11211-6259
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-384-3600
-----------------------------------------------------
Fax | 718-384-3660
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 175 MARCY AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11211-6259
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-384-3600
-----------------------------------------------------
Fax | 718-384-3660
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MRS. DAVID B COHEN
-----------------------------------------------------
Credential | LDO
-----------------------------------------------------
Telephone | 718-384-3600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | TUV 005485
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------