Provider Demographics
NPI:1497147524
Name:GREEN VISION OPTICIAN P.C.
Entity Type:Organization
Organization Name:GREEN VISION OPTICIAN P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ELIZA
Authorized Official - Middle Name:
Authorized Official - Last Name:IOSILEVICH
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:347-757-5475
Mailing Address - Street 1:404 EAST 117 ST
Mailing Address - Street 2:#1
Mailing Address - City:NY
Mailing Address - State:NY
Mailing Address - Zip Code:10035
Mailing Address - Country:US
Mailing Address - Phone:917-688-7439
Mailing Address - Fax:
Practice Address - Street 1:404 EAST 117 ST
Practice Address - Street 2:#1
Practice Address - City:NY
Practice Address - State:NY
Practice Address - Zip Code:10035
Practice Address - Country:US
Practice Address - Phone:917-688-7439
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-26
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009190-1261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health