Provider Demographics
NPI:1568530079
Name:BURNSIDE OPTICAL INC.
Entity Type:Organization
Organization Name:BURNSIDE OPTICAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GUILLERMO
Authorized Official - Middle Name:YSMAEL
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-299-5454
Mailing Address - Street 1:54 W BURNSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10453-4018
Mailing Address - Country:US
Mailing Address - Phone:718-299-5454
Mailing Address - Fax:718-299-0770
Practice Address - Street 1:54 W BURNSIDE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-4018
Practice Address - Country:US
Practice Address - Phone:718-299-5454
Practice Address - Fax:718-299-0770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0073791156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01956270Medicaid