Provider Demographics
NPI:1942285721
Name:BARRY SCOTT RAINES
Entity Type:Organization
Organization Name:BARRY SCOTT RAINES
Other - Org Name:WAVECREST OPTICAL SHOP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTICIAN/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:RAINES
Authorized Official - Suffix:
Authorized Official - Credentials:OPHTHALMIC DISPENSER
Authorized Official - Phone:718-327-2020
Mailing Address - Street 1:257 BEACH 20TH ST
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-3625
Mailing Address - Country:US
Mailing Address - Phone:718-327-2020
Mailing Address - Fax:718-327-3429
Practice Address - Street 1:257 BEACH 20TH ST
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-3625
Practice Address - Country:US
Practice Address - Phone:718-327-2020
Practice Address - Fax:718-327-3429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-14
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005665332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01136483Medicaid
NYA08002326Medicare ID - Type UnspecifiedNSC SUB. NO.