Provider Demographics
NPI:1508194689
Name:HILLSIDE OPTICAL CORP.
Entity Type:Organization
Organization Name:HILLSIDE OPTICAL CORP.
Other - Org Name:FABULOUS OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BANGIYEV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-658-0900
Mailing Address - Street 1:8902 165TH ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-5126
Mailing Address - Country:US
Mailing Address - Phone:718-658-0900
Mailing Address - Fax:
Practice Address - Street 1:8902 165TH ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-5126
Practice Address - Country:US
Practice Address - Phone:718-658-0900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-30
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007405152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty