=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942621651
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPTICS BY MBM INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/23/2013
-----------------------------------------------------
Last Update Date | 12/23/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 HARWOOD CT
-----------------------------------------------------
City | SCARSDALE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10583-4104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-472-8900
-----------------------------------------------------
Fax | 914-472-8901
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 HARWOOD CT
-----------------------------------------------------
City | SCARSDALE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10583-4104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-472-8900
-----------------------------------------------------
Fax | 914-472-8901
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. BARRY S GROSSBAUM
-----------------------------------------------------
Credential | OPTICIAN
-----------------------------------------------------
Telephone | 914-472-8900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 004544-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------