=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689044067
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRONX VISTA INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2015
-----------------------------------------------------
Last Update Date | 01/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 455 E 149TH ST
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10455-1314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-292-2020
-----------------------------------------------------
Fax | 718-585-1285
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 455 E 149TH STREET
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10455-1314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-292-2020
-----------------------------------------------------
Fax | 718-585-1285
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. OLEG LISITSYN
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 718-292-2002
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 006388
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------