MEDICARE: GRACE EYECARE

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	TUV006890	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C478C1	OTHER	NY	EMPIRE BLUE CROSS BLUE SHIELD
2	P3686293	OTHER	NY	OXFORD

General Provider Information

NPI Number	:	1568605814
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE EYECARE

Provider Business Mailing Address
First Line	:	1615 CORTELYOU RD
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11226-5209
Country	:	US
Telephone Number	:	718-826-2020
Fax Number	:

Provider Business Practice Location Address
First Line	:	1615 CORTELYOU RD
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11226-5209
Country	:	US
Telephone Number	:	718-826-2020
Fax Number	:

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	DR. WIDAD ARTAGRACE VALME
Credential	:	OD
Telephone Number	:	719-826-2020

Provider Enumeration Date	:	04/16/2009
Last Update Date	:	04/08/2010

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Directions to “GRACE EYECARE ” Practice Location

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