Basic Information
| Provider Information | |||||||||
| NPI: | 1891021440 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EYECARE ADVANTAGE, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | EYECARE VISION SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1953 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | NORTH BALDWIN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115102820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8554233700 | ||||||||
| FaxNumber: | 6314993062 | ||||||||
| Practice Location | |||||||||
| Address1: | 5752 MYRTLE AVE | ||||||||
| Address2: | |||||||||
| City: | RIDGEWOOD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113854940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8554233700 | ||||||||
| FaxNumber: | 6314993062 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2009 | ||||||||
| LastUpdateDate: | 10/03/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ASHINOFF | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8554233700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | OD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | 003162 | NY | N | Suppliers | Eyewear Supplier (Equipment, not the service) | 152W00000X | T003162 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.