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General NPI Number Information
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NPI Number | 1619096815
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Entity Type | Organization
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Legal Business Name | STATEN EYE LAND 2 INC
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Dates
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Enumeration Date | 03/28/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1803 VICTORY BLVD
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City | STATEN ISLAND
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State | NY
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Zip | 10314-3515
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Country | US
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Telephone | 718-448-7676
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Fax | 718-448-7675
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Provider Business Mailing Address
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Address Line | 1803 VICTORY BLVD
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City | STATEN ISLAND
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State | NY
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Zip | 10314-3515
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Country | US
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Telephone | 718-448-7676
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Fax | 718-448-7675
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Authorized Official
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Title or Position | OWNER
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Name | MR. ALAN FRUCHTMAN
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Credential | OPTICIAN
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Telephone | 714-448-7676
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number | 004036-1
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License Number State | NY
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