Provider Demographics
NPI:1063791556
Name:MILLBROOK FAMILY EYECARE, INC
Entity type:Organization
Organization Name:MILLBROOK FAMILY EYECARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:KRALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-677-5012
Mailing Address - Street 1:61 FRONT ST
Mailing Address - Street 2:P.O. BOX 570
Mailing Address - City:MILLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:12545-5961
Mailing Address - Country:US
Mailing Address - Phone:845-677-5012
Mailing Address - Fax:845-677-5024
Practice Address - Street 1:61 FRONT ST
Practice Address - Street 2:
Practice Address - City:MILLBROOK
Practice Address - State:NY
Practice Address - Zip Code:12545-5961
Practice Address - Country:US
Practice Address - Phone:845-677-5012
Practice Address - Fax:845-677-5024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-15
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03372887Medicaid
NYA100056547Medicare PIN