Provider Demographics
NPI:1245261593
Name:EYELLUSION VISION CENTER INCORPORATED
Entity type:Organization
Organization Name:EYELLUSION VISION CENTER INCORPORATED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:HERMINIO
Authorized Official - Middle Name:V
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:718-639-1392
Mailing Address - Street 1:6909 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-2933
Mailing Address - Country:US
Mailing Address - Phone:718-639-1392
Mailing Address - Fax:718-639-2041
Practice Address - Street 1:6909 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-2933
Practice Address - Country:US
Practice Address - Phone:718-639-1392
Practice Address - Fax:718-639-2041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006666156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02291789Medicaid
NY44101OtherDAVIS VISION
NY5499979OtherGHI
NMNY6666OtherEYEMED
NY333641OtherNVA
NYEV14830OtherSPECTERA
NY205119OtherCOLE MANAGED
NY7186391392OtherHIP
NY05450Medicare ID - Type Unspecified