Provider Demographics
NPI:1952419053
Name:WIZARD OF EYES OF 116 ST INC
Entity Type:Organization
Organization Name:WIZARD OF EYES OF 116 ST INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-996-7676
Mailing Address - Street 1:187 E 116TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-1342
Mailing Address - Country:US
Mailing Address - Phone:212-996-7676
Mailing Address - Fax:
Practice Address - Street 1:187 E 116TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-1342
Practice Address - Country:US
Practice Address - Phone:212-996-7676
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01181057Medicaid
NYA100133294OtherMEDICARE PTAN