=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912275397
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYEGLASS DEPOT OPTICAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2011
-----------------------------------------------------
Last Update Date | 12/13/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 60 WILLOW PARK CTR
-----------------------------------------------------
City | FARMINGDALE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11735-1001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-777-7283
-----------------------------------------------------
Fax | 631-777-3329
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 60 WILLOW PARK CTR
-----------------------------------------------------
City | FARMINGDALE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11735-1001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-777-7283
-----------------------------------------------------
Fax | 631-777-3329
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | DEENA FELDMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 631-777-7283
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------