Provider Demographics
NPI:1043072770
Name:5623 NYC OPTICAL LLC
Entity Type:Organization
Organization Name:5623 NYC OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:GAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:929-924-6019
Mailing Address - Street 1:5623 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-3414
Mailing Address - Country:US
Mailing Address - Phone:718-635-9333
Mailing Address - Fax:718-765-1113
Practice Address - Street 1:5623 5TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-3414
Practice Address - Country:US
Practice Address - Phone:718-635-9333
Practice Address - Fax:718-765-1113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty