Provider Demographics
NPI:1235361460
Name:KINGSBORO OPTOMETRIC PC
Entity Type:Organization
Organization Name:KINGSBORO OPTOMETRIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GENA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOCHIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:917-865-9174
Mailing Address - Street 1:2750 HOMECREST AVE
Mailing Address - Street 2:SUITE 216
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-4656
Mailing Address - Country:US
Mailing Address - Phone:917-865-9174
Mailing Address - Fax:
Practice Address - Street 1:6603 BAY PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-3934
Practice Address - Country:US
Practice Address - Phone:718-259-8489
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-21
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYV005778152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty