=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821523176
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYE TO EYE OPTICAL CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2017
-----------------------------------------------------
Last Update Date | 04/25/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 88 S 6TH ST
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11249-6028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-844-9952
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 88 S 6TH ST
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11249-6028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-844-9952
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NINA YUSUPOVA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 347-844-9952
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | TUV007771
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------