Provider Demographics
NPI:1841971306
Name:MIRAKOVA, LARISA
Entity type:Individual
Prefix:
First Name:LARISA
Middle Name:
Last Name:MIRAKOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:LUXURY VISION CENTER
Mailing Address - Street 2:1125 LIBERTY AVE
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11208
Mailing Address - Country:US
Mailing Address - Phone:917-471-9505
Mailing Address - Fax:
Practice Address - Street 1:LUXURY VISION CENTER
Practice Address - Street 2:1125 LIBERTY AVE
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11208
Practice Address - Country:US
Practice Address - Phone:917-471-9505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008101156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty