Provider Demographics
NPI:1164542916
Name:LARCHMONT MAMARONECK EYE CARE GROUP
Entity Type:Organization
Organization Name:LARCHMONT MAMARONECK EYE CARE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:FENGEL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:914-698-2182
Mailing Address - Street 1:933 MAMARONECK AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:MAMARONECK
Mailing Address - State:NY
Mailing Address - Zip Code:10543-1662
Mailing Address - Country:US
Mailing Address - Phone:914-698-2182
Mailing Address - Fax:914-381-2676
Practice Address - Street 1:933 MAMARONECK AVE
Practice Address - Street 2:
Practice Address - City:MAMARONECK
Practice Address - State:NY
Practice Address - Zip Code:10543-1662
Practice Address - Country:US
Practice Address - Phone:914-698-2182
Practice Address - Fax:914-381-2676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV0045721152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400004912Medicare PIN
NYA100000550Medicare PIN
NYA400004913Medicare PIN
NYA400004914Medicare PIN