MEDICARE: OPTIQUE ELEGANCE, LLC

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	156FX1800X	Optician	4931	NY

General Provider Information

NPI Number	:	1346452257
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTIQUE ELEGANCE, LLC

Provider Business Mailing Address
First Line	:	3410 AVENUE N
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11234-2607
Country	:	US
Telephone Number	:	718-421-0075
Fax Number	:	718-421-3839

Provider Business Practice Location Address
First Line	:	3410 AVENUE N
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11234-2607
Country	:	US
Telephone Number	:	718-421-0075
Fax Number	:	718-421-3839

Authorized Official
Title or Position	:	CEO
Name	:	PHYLLIS BUDNITZ
Credential	:	OPTICIAN
Telephone Number	:	718-421-0075

Provider Enumeration Date	:	05/04/2007
Last Update Date	:	08/22/2020

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