Provider Demographics
NPI:1609055581
Name:ATLANTIC OPTICAL, INC
Entity Type:Organization
Organization Name:ATLANTIC OPTICAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALLA
Authorized Official - Middle Name:
Authorized Official - Last Name:DYATLOV
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:718-522-3737
Mailing Address - Street 1:139 FLATBUSH AVE
Mailing Address - Street 2:#15
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-1450
Mailing Address - Country:US
Mailing Address - Phone:718-522-3737
Mailing Address - Fax:718-522-3894
Practice Address - Street 1:139 FLATBUSH AVE
Practice Address - Street 2:#15
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-1450
Practice Address - Country:US
Practice Address - Phone:718-522-3737
Practice Address - Fax:718-522-3894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV006692152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02950223Medicaid
WYRQZ1Medicare PIN