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General NPI Number Information
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NPI Number | 1740402205
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Entity Type | Organization
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Legal Business Name | PELHAM PARKWAY VISION CENTER INC
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Dates
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Enumeration Date | 05/03/2007
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Last Update Date | 04/14/2021
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Provider Practice Location Address
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Address Line | 731 LYDIG AVE
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City | BRONX
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State | NY
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Zip | 10462-2103
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Country | US
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Telephone | 718-829-2160
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Fax | 718-829-9502
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Provider Business Mailing Address
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Address Line | 735 LYDIG AVE
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City | BRONX
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State | NY
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Zip | 10462-2103
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Country | US
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Telephone | 718-829-2160
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Fax | 718-829-9502
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Authorized Official
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Title or Position | PART OWNER
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Name | OLEG LISITSYN
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Credential | OD
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Telephone | 718-829-2160
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152WV0400X
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Taxonomy Name | Vision Therapy Optometrist
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License Number | 006388
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License Number State | NY
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