MEDICARE: SPECSTACULAR II

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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1376818096
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPECSTACULAR II

Provider Business Mailing Address
First Line	:	154 MONTAGUE ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11201-3538
Country	:	US
Telephone Number	:	718-246-5795
Fax Number	:	718-222-1141

Provider Business Practice Location Address
First Line	:	154 MONTAGUE ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11201-3538
Country	:	US
Telephone Number	:	718-246-5795
Fax Number	:	718-222-1141

Authorized Official
Title or Position	:	OWNER/OPTICIAN
Name	:	MS. LYDIA BARCELONA STRONG
Credential	:
Telephone Number	:	718-246-5795

Provider Enumeration Date	:	03/13/2012
Last Update Date	:	03/13/2012

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