Provider Demographics
NPI:1366627036
Name:LIBERTY OPTICAL INC
Entity Type:Organization
Organization Name:LIBERTY OPTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VLADIMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:POLEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:516-869-5998
Mailing Address - Street 1:572 PLANDOME RD
Mailing Address - Street 2:
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-1946
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:572 PLANDOME RD
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-1946
Practice Address - Country:US
Practice Address - Phone:516-869-5998
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-31
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006252152W00000X
NY006241152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6104120001Medicare NSC