Provider Demographics
NPI:1487078408
Name:KRUGOLETS, ELLA
Entity type:Individual
Prefix:
First Name:ELLA
Middle Name:
Last Name:KRUGOLETS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 LIDO BLVD APT 81B
Mailing Address - Street 2:
Mailing Address - City:LIDO BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-5243
Mailing Address - Country:US
Mailing Address - Phone:646-420-1292
Mailing Address - Fax:
Practice Address - Street 1:2201 HEMPSTEAD TPKE
Practice Address - Street 2:
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554
Practice Address - Country:US
Practice Address - Phone:516-572-6646
Practice Address - Fax:516-572-9477
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-11
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006682156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician