Provider Demographics
NPI:1033278544
Name:104TH ST OPTICAL INC
Entity Type:Organization
Organization Name:104TH ST OPTICAL INC
Other - Org Name:SIGHT N STYLE OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:
Authorized Official - Last Name:SINOWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-831-4733
Mailing Address - Street 1:1884 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029
Mailing Address - Country:US
Mailing Address - Phone:212-831-4733
Mailing Address - Fax:212-831-0141
Practice Address - Street 1:1884 3RD AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029
Practice Address - Country:US
Practice Address - Phone:212-831-4733
Practice Address - Fax:212-831-0141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Not Answered332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY59C0310OtherCOMMUNITY PREMIER PLUS
NY02687667Medicaid