=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699168526
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VISITING VISION SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2015
-----------------------------------------------------
Last Update Date | 03/17/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 571 WINDSOR DR
-----------------------------------------------------
City | PALISADES PARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07650-2363
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-421-9321
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 571 WINDSOR DR
-----------------------------------------------------
City | PALISADES PARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07650-2363
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-421-9321
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | YULIA NAUMOVA
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 201-421-9321
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 27OA00652600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------