MEDICARE: PURE EYECARE OPTOMETRY P.C.

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	261QM2500X	Medical Specialty Clinic/Center

General Provider Information

NPI Number	:	1285278606
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PURE EYECARE OPTOMETRY P.C.

Provider Business Mailing Address
First Line	:	10537 65TH AVE APT 4D
Second Line	:
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-1818
Country	:	US
Telephone Number	:	917-476-7757
Fax Number	:

Provider Business Practice Location Address
First Line	:	10537 65TH AVE APT 4D
Second Line	:
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-1818
Country	:	US
Telephone Number	:	917-476-7757
Fax Number	:

Authorized Official
Title or Position	:	DOCTOR OF OPTOMETRY
Name	:	DR. ROMAN KAKZANOV
Credential	:	OD
Telephone Number	:	917-476-7757

Provider Enumeration Date	:	10/29/2019
Last Update Date	:	10/29/2019

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