=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649391285
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUPERIOR VISION OF NEW YORK, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2007
-----------------------------------------------------
Last Update Date | 02/16/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4767 BROADWAY
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10034-4915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-567-9351
-----------------------------------------------------
Fax | 212-567-3370
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4767 BROADWAY
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10034-4915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-567-9351
-----------------------------------------------------
Fax | 212-567-3370
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. ROBERT HERNANDEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 212-567-9351
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | TUV003223-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------