Provider Demographics
NPI:1265763148
Name:RICK, IGOR
Entity type:Individual
Prefix:
First Name:IGOR
Middle Name:
Last Name:RICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 GREEN ACRES MALL
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-1536
Mailing Address - Country:US
Mailing Address - Phone:516-825-4900
Mailing Address - Fax:
Practice Address - Street 1:1112 GREEN ACRES MALL
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11581-1536
Practice Address - Country:US
Practice Address - Phone:516-825-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-16
Last Update Date:2010-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007236156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician