=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497992069
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NY OPTIX LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2009
-----------------------------------------------------
Last Update Date | 01/19/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1823 AVENUE M
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11230-5308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-377-5649
-----------------------------------------------------
Fax | 718-377-1935
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1823 AVENUE M
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11230-5308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-377-5649
-----------------------------------------------------
Fax | 718-377-1935
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. YAAKOV SHEINHOUSE
-----------------------------------------------------
Credential | LICENSED OPTICIAN
-----------------------------------------------------
Telephone | 718-377-5649
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 007414
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------