Provider Demographics
NPI:1578773081
Name:FOURTH AVENUE VISION CENTER
Entity Type:Organization
Organization Name:FOURTH AVENUE VISION CENTER
Other - Org Name:FOURTH AVENUE VISION CENTER, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CLAIRE
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCADAMO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-664-4600
Mailing Address - Street 1:55 S 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:MT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550-3104
Mailing Address - Country:US
Mailing Address - Phone:914-664-4600
Mailing Address - Fax:
Practice Address - Street 1:55 S. FOURTH AVE.
Practice Address - Street 2:
Practice Address - City:MT. VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-3104
Practice Address - Country:US
Practice Address - Phone:914-664-4600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002488152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02902789Medicaid