=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982148763
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROADWAY MALL VISION EXPRESS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2016
-----------------------------------------------------
Last Update Date | 12/13/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 358 BROADWAY MALL BROADWAY MALL SUITE 371A
-----------------------------------------------------
City | HICKSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11801-2709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-938-0055
-----------------------------------------------------
Fax | 516-938-8667
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 358 BROADWAY MALL BROADWAY MALL SUITE 371A
-----------------------------------------------------
City | HICKSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11801-2709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-938-0055
-----------------------------------------------------
Fax | 516-938-8667
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | LEONID VAYNER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 516-938-0055
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 005761
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------