=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821230061
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIBERTY EYES INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2009
-----------------------------------------------------
Last Update Date | 03/14/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11510 LIBERTY AVE
-----------------------------------------------------
City | SOUTH RICHMOND HILL
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11419-1902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-323-6410
-----------------------------------------------------
Fax | 718-323-6410
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11510 LIBERTY AVE
-----------------------------------------------------
City | SOUTH RICHMOND HILL
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11419-1902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-323-6410
-----------------------------------------------------
Fax | 718-323-6375
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. NATALIE NGUYEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-323-6410
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | TUV006759
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------