Provider Demographics
NPI:1235538596
Name:LIBERTY OPTICAL CORP
Entity Type:Organization
Organization Name:LIBERTY OPTICAL CORP
Other - Org Name:FABULOUS OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BARAYEV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-835-3400
Mailing Address - Street 1:12102 LIBERTY AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11419-2112
Mailing Address - Country:US
Mailing Address - Phone:718-835-3400
Mailing Address - Fax:
Practice Address - Street 1:12102 LIBERTY AVE
Practice Address - Street 2:
Practice Address - City:SOUTH RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11419-2112
Practice Address - Country:US
Practice Address - Phone:718-835-3400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-22
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007786152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty