Provider Demographics
NPI:1144392549
Name:BUENA VISTA VISION CENTER, INC
Entity Type:Organization
Organization Name:BUENA VISTA VISION CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:ALBERTO
Authorized Official - Last Name:DE LA ROSA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:212-926-0336
Mailing Address - Street 1:3777 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-1541
Mailing Address - Country:US
Mailing Address - Phone:212-926-0336
Mailing Address - Fax:212-926-0212
Practice Address - Street 1:3777 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1541
Practice Address - Country:US
Practice Address - Phone:212-926-0336
Practice Address - Fax:212-926-0212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV005619152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY919634OtherBLOCK VISION
NY2129260336OtherVSP
NY43658OtherDAVIS VISION
NY02334141Medicaid
NYCAWKL1Medicare PIN
NY919634OtherBLOCK VISION
NY02334141Medicaid