=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467103499
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUNSET EYECARE PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2022
-----------------------------------------------------
Last Update Date | 01/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1148 DEER PARK AVE
-----------------------------------------------------
City | NORTH BABYLON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11703-3102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-242-0808
-----------------------------------------------------
Fax | 631-272-3683
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1148 DEER PARK AVE
-----------------------------------------------------
City | NORTH BABYLON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11703-3102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-242-0808
-----------------------------------------------------
Fax | 631-272-3683
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. PETER FONG
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 330-708-4184
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------