Provider Demographics
NPI:1083850341
Name:KINGS HIGHWAY OPTICAL CORP.
Entity Type:Organization
Organization Name:KINGS HIGHWAY OPTICAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ELAINA
Authorized Official - Middle Name:
Authorized Official - Last Name:ZAVILENSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-627-8900
Mailing Address - Street 1:1302 KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-1960
Mailing Address - Country:US
Mailing Address - Phone:718-627-8900
Mailing Address - Fax:718-376-4272
Practice Address - Street 1:1302 KINGS HWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-1960
Practice Address - Country:US
Practice Address - Phone:718-627-8900
Practice Address - Fax:718-376-4272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-16
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV0032361152W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA100022235Medicare PIN