Provider Demographics
NPI:1427351485
Name:EMANI & DIVINE EYES, INC.
Entity type:Organization
Organization Name:EMANI & DIVINE EYES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:RANDOLPH
Authorized Official - Last Name:ELLISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-291-2370
Mailing Address - Street 1:97-04 ROCKAWAY BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11693-1313
Mailing Address - Country:US
Mailing Address - Phone:718-474-0064
Mailing Address - Fax:
Practice Address - Street 1:97-04 ROCKAWAY BEACH BLVD
Practice Address - Street 2:
Practice Address - City:ROCKAWAY BEACH
Practice Address - State:NY
Practice Address - Zip Code:11693-1313
Practice Address - Country:US
Practice Address - Phone:718-474-0064
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-14
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008765305S00000X
NY0066601305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1023325107Medicaid