Provider Demographics
NPI:1952559833
Name:MGL VISION LLC
Entity Type:Organization
Organization Name:MGL VISION LLC
Other - Org Name:MACYS VISION EXPRESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:EPPEL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:516-823-4267
Mailing Address - Street 1:1000 GREEN ACRES MALL
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-1533
Mailing Address - Country:US
Mailing Address - Phone:516-823-4267
Mailing Address - Fax:
Practice Address - Street 1:1000 GREEN ACRES MALL
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11581-1533
Practice Address - Country:US
Practice Address - Phone:516-823-4267
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02082768Medicaid
NY02082768Medicaid