Provider Demographics
NPI:1669827960
Name:IMPULSE DESIGNER EYEWEAR CORP
Entity Type:Organization
Organization Name:IMPULSE DESIGNER EYEWEAR CORP
Other - Org Name:EYEGLASS FACTORY ON BROADWAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-271-1782
Mailing Address - Street 1:83-19 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373
Mailing Address - Country:US
Mailing Address - Phone:718-271-1782
Mailing Address - Fax:
Practice Address - Street 1:83-19 BROADWAY
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373
Practice Address - Country:US
Practice Address - Phone:718-271-1782
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-25
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact LensGroup - Multi-Specialty
No156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens FitterGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty