Provider Demographics
NPI:1346300548
Name:BRENTWOOD VISION CENTER INC
Entity Type:Organization
Organization Name:BRENTWOOD VISION CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:S
Authorized Official - Last Name:LOFORTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-273-3335
Mailing Address - Street 1:601 SUFFOLK AVENUE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-4309
Mailing Address - Country:US
Mailing Address - Phone:631-273-3335
Mailing Address - Fax:631-273-0310
Practice Address - Street 1:601 SUFFOLK AVENUE
Practice Address - Street 2:SUITE 1
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-4309
Practice Address - Country:US
Practice Address - Phone:631-273-3335
Practice Address - Fax:631-273-0310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY67930152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00461867Medicaid
NY0428500001Medicare NSC