MEDICARE: 349 KNICKERBOCKER INC.

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		NY

General Provider Information

NPI Number	:	1376710798
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	349 KNICKERBOCKER INC.

Provider Business Mailing Address
First Line	:	783 EVERGREEN DR
Second Line	:
City	:	WEST HEMPSTEAD
State	:	NY
Zip	:	11552-3406
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	341 KNICKERBOCKER AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11237-3740
Country	:	US
Telephone Number	:	718-418-1268
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DAVID FEDER
Credential	:
Telephone Number	:	718-418-1268

Provider Enumeration Date	:	05/14/2008
Last Update Date	:	05/14/2008

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