MEDICARE: 154 MONTAGUE STR 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	152W00000X	Optometrist

General Provider Information

NPI Number	:	1356166615
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	154 MONTAGUE STR LLC

Provider Business Mailing Address
First Line	:	154 MONTAGUE ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11201-3538
Country	:	US
Telephone Number	:	917-805-3419
Fax Number	:

Provider Business Practice Location Address
First Line	:	154 MONTAGUE ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11201-3538
Country	:	US
Telephone Number	:	917-279-4794
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MR. ERNEST KATSEV
Credential	:
Telephone Number	:	917-805-3419

Provider Enumeration Date	:	11/20/2024
Last Update Date	:	02/03/2025

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