Provider Demographics
NPI:1982148763
Name:BROADWAY MALL VISION EXPRESS, LLC
Entity type:Organization
Organization Name:BROADWAY MALL VISION EXPRESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEONID
Authorized Official - Middle Name:
Authorized Official - Last Name:VAYNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-938-0055
Mailing Address - Street 1:358 BROADWAY MALL
Mailing Address - Street 2:BROADWAY MALL SUITE 371A
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-2709
Mailing Address - Country:US
Mailing Address - Phone:516-938-0055
Mailing Address - Fax:516-938-8667
Practice Address - Street 1:358 BROADWAY MALL
Practice Address - Street 2:BROADWAY MALL SUITE 371A
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-2709
Practice Address - Country:US
Practice Address - Phone:516-938-0055
Practice Address - Fax:516-938-8667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-13
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005761332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier