Provider Demographics
NPI:1265106496
Name:SUPREME VISION CENTER INC
Entity type:Organization
Organization Name:SUPREME VISION CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BANGIYEV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-866-1740
Mailing Address - Street 1:200 W 125TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-4410
Mailing Address - Country:US
Mailing Address - Phone:212-665-5051
Mailing Address - Fax:212-203-0399
Practice Address - Street 1:691H COOP CITY BLVD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10475-1673
Practice Address - Country:US
Practice Address - Phone:917-642-1035
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-02
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty