Provider Demographics
NPI:1619306123
Name:EYEWEAR PALACE INC.
Entity Type:Organization
Organization Name:EYEWEAR PALACE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLESNYK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-915-0791
Mailing Address - Street 1:395 FLATBUSH AVENUE EXT
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-5300
Mailing Address - Country:US
Mailing Address - Phone:718-625-7500
Mailing Address - Fax:
Practice Address - Street 1:395 FLATBUSH AVENUE EXT
Practice Address - Street 2:STORE # 8
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5300
Practice Address - Country:US
Practice Address - Phone:718-625-7500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY152W00000X, 152WL0500X, 156FC0800X, 156FX1800X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty
No156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact LensGroup - Single Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02967568Medicaid