MEDICARE: FOURTH AVENUE VISION CENTER

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	002488	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578773081
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOURTH AVENUE VISION CENTER

Provider Business Mailing Address
First Line	:	55 S 4TH AVE
Second Line	:
City	:	MT VERNON
State	:	NY
Zip	:	10550-3104
Country	:	US
Telephone Number	:	914-664-4600
Fax Number	:

Provider Business Practice Location Address
First Line	:	55 S. FOURTH AVE.
Second Line	:
City	:	MT. VERNON
State	:	NY
Zip	:	10550-3104
Country	:	US
Telephone Number	:	914-664-4600
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. CLAIRE LUCADAMO
Credential	:
Telephone Number	:	914-664-4600

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	10/04/2007

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