Provider Demographics
NPI:1386033868
Name:VICTORY VISION CENTER LLC
Entity Type:Organization
Organization Name:VICTORY VISION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VIKTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLESNYK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-915-0791
Mailing Address - Street 1:565 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-1913
Mailing Address - Country:US
Mailing Address - Phone:718-915-0791
Mailing Address - Fax:718-622-5404
Practice Address - Street 1:565 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-1913
Practice Address - Country:US
Practice Address - Phone:718-915-0791
Practice Address - Fax:718-622-5404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-21
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008816152W00000X, 156FC0801X
NY008716332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens FitterGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02857014Medicaid