MEDICARE: IBMB OPTICAL CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	305S00000X	Point of Service
2	332H00000X	Eyewear Supplier

General Provider Information

NPI Number	:	1215102827
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IBMB OPTICAL CORP

Provider Business Mailing Address
First Line	:	2603 BATH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11214-5501
Country	:	US
Telephone Number	:	347-492-4353
Fax Number	:	347-492-4355

Provider Business Practice Location Address
First Line	:	2603 BATH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11214-5501
Country	:	US
Telephone Number	:	347-492-4353
Fax Number	:	347-492-4355

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. MARK BARAYEV
Credential	:
Telephone Number	:	347-492-4353

Provider Enumeration Date	:	04/24/2008
Last Update Date	:	04/24/2008

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Directions to “IBMB OPTICAL CORP ” Practice Location

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