Provider Demographics
NPI:1376095992
Name:RALPH PLACE OPTICAL LLC
Entity Type:Organization
Organization Name:RALPH PLACE OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FARZAD
Authorized Official - Middle Name:
Authorized Official - Last Name:FAKHERI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-720-2001
Mailing Address - Street 1:8 RIDGEWAY DR
Mailing Address - Street 2:
Mailing Address - City:KINGS POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11024-1435
Mailing Address - Country:US
Mailing Address - Phone:718-720-2001
Mailing Address - Fax:
Practice Address - Street 1:11 RALPH PL
Practice Address - Street 2:SUITE 101
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-4401
Practice Address - Country:US
Practice Address - Phone:718-720-2001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-31
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV004573152W00000X
NY191296207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty