Provider Demographics
NPI:1962145417
Name:OPTIC SHADES 2ND AVE INC
Entity type:Organization
Organization Name:OPTIC SHADES 2ND AVE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YURIY
Authorized Official - Middle Name:
Authorized Official - Last Name:NEKTALOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-686-8666
Mailing Address - Street 1:577 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6377
Mailing Address - Country:US
Mailing Address - Phone:212-686-8666
Mailing Address - Fax:
Practice Address - Street 1:577 2ND AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6377
Practice Address - Country:US
Practice Address - Phone:212-686-8666
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-13
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty