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General NPI Number Information
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NPI Number | 1891722138
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Entity Type | Organization
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Legal Business Name | EYESITE VISION III INCORPORATION
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Dates
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Enumeration Date | 06/26/2006
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Last Update Date | 04/13/2017
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Provider Practice Location Address
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Address Line | 446 KNICKERBOCKER AVE
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City | BROOKLYN
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State | NY
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Zip | 11237-4509
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Country | US
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Telephone | 718-455-6500
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Fax | 718-455-6507
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Provider Business Mailing Address
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Address Line | 248 KENSINGTON LYNBROOK
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City | LONG ISLAND
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State | NY
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Zip | 11563-2711
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Country | US
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Telephone | 917-650-0190
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. CLEMENT E IDEHEN
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Credential | O.D
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Telephone | 917-650-0190
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | VUT006065
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License Number State | NY
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