Provider Demographics
NPI:1164156261
Name:PURE VISION OPTICAL 2 LLC
Entity Type:Organization
Organization Name:PURE VISION OPTICAL 2 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OREN
Authorized Official - Middle Name:
Authorized Official - Last Name:YAKUBOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-670-5116
Mailing Address - Street 1:53 W FORDHAM RD FRNT 4
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10468-5110
Mailing Address - Country:US
Mailing Address - Phone:917-670-5116
Mailing Address - Fax:
Practice Address - Street 1:53 W FORDHAM RD FRNT 4
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-5110
Practice Address - Country:US
Practice Address - Phone:917-670-5116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty