Provider Demographics
NPI:1003176603
Name:MAIN OPTICAL LLC
Entity type:Organization
Organization Name:MAIN OPTICAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDUARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BORUKHOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-642-2593
Mailing Address - Street 1:6830 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-1325
Mailing Address - Country:US
Mailing Address - Phone:718-575-3937
Mailing Address - Fax:718-261-2191
Practice Address - Street 1:6830 MAIN ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11367-1325
Practice Address - Country:US
Practice Address - Phone:718-575-3937
Practice Address - Fax:718-261-2191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-17
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009250156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty