Provider Demographics
NPI:1962916940
Name:CONCIERGE PREMIUM EYECARE LLC
Entity type:Organization
Organization Name:CONCIERGE PREMIUM EYECARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAJAT
Authorized Official - Middle Name:
Authorized Official - Last Name:SHETTY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:718-734-2509
Mailing Address - Street 1:2176 21ST ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-3618
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2556 CRESCENT ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11102-2938
Practice Address - Country:US
Practice Address - Phone:718-344-1272
Practice Address - Fax:718-425-9803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-29
Last Update Date:2021-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008009152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06247570Medicaid