Provider Demographics
NPI:1922706779
Name:MK VISION CENTER STATEN ISLAND LLC
Entity Type:Organization
Organization Name:MK VISION CENTER STATEN ISLAND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-203-8979
Mailing Address - Street 1:1803 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-3515
Mailing Address - Country:US
Mailing Address - Phone:845-495-3658
Mailing Address - Fax:
Practice Address - Street 1:1803 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3515
Practice Address - Country:US
Practice Address - Phone:845-495-3658
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-21
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty