Provider Demographics
NPI:1952852360
Name:EYELLUSION VISION CENTER INCORPORATED
Entity type:Organization
Organization Name:EYELLUSION VISION CENTER INCORPORATED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HERMINIO
Authorized Official - Middle Name:
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSED OPTICIAN
Authorized Official - Phone:516-829-1010
Mailing Address - Street 1:1441 OLD COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-5010
Mailing Address - Country:US
Mailing Address - Phone:516-962-9551
Mailing Address - Fax:516-962-5997
Practice Address - Street 1:1441 OLD COUNTRY RD
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-5010
Practice Address - Country:US
Practice Address - Phone:516-962-9551
Practice Address - Fax:516-962-5997
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EYELLUSION VISION CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-20
Last Update Date:2022-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006666156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02291789Medicaid
NYG100232557Medicare UPIN